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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005410
Report Date: 05/10/2024
Date Signed: 05/14/2024 02:29:58 PM

Document Has Been Signed on 05/14/2024 02:29 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:SCHUMARD CARE HOMEFACILITY NUMBER:
397005410
ADMINISTRATOR/
DIRECTOR:		DIZON, JESSICAFACILITY TYPE:
735
ADDRESS:18268 SCHUMARD OAK ROADTELEPHONE:
(209) 323-5590
CITY:LATHROPSTATE: CAZIP CODE:
95330
CAPACITY: 6CENSUS: 6DATE:
05/10/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Jazmine CastilloTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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Unannounced case management visit made out to this facility on 05/10/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility house manager, Jazmine Castillo, who was briefly interviewed at this time. This LPA also requested that she go ahead and notify the facility designated Administrator, Jessica Dizon, to let her know that CCL was present at this time.
Current census was 6 residents but all of them were out of the home at this time at their respectable day programs.
The purpose of this visit was to deliver the findings of a recent audit that focused around a death that occurred at this facility involving R1 at that time.
Based on a review of the records conducted by this Department it was concluded that this facility failed to provide timely medical assistance for R1.

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulation, Health and Safety Codes.

A civil penalty in the amount of $500 was issued today on the following LIC 421 IM.

Appeal rights were printed and a copy was given to the facility house manager, Jazmine Castillo, at this time.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/14/2024 02:29 PM - It Cannot Be Edited


Created By: Charlie Yang On 05/10/2024 at 01:40 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SCHUMARD CARE HOME
FACILITY NUMBER: 397005410

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/11/2024
Section Cited
CCR
85075.4(c)

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The licensee shall bring observed changes, including but not limited to unusual weight gains or losses, or deterioration of health condition, to the attention of the client's physician and authorized representative, if any.
This facility was found to be deficient as
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The facility representative stated that all facility staff providing care and supervision to the residents in care will be trained. This training will be for no less than (2) hours in duration on the subject matter of observing changes and properly reporting it to all involved parties and representatives.
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evidenced by not noting that considerable changes had taken place with a resident's health as it progressively declined. Medical attention was not properly sought nor were the client's physician and authorized representative(s) informed which posed an immediate threat to the Health, Safety and Personal Rights of residents in care.
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A statement of correction, along with proof of updated training, will be completed and submitted into CCL by the due date. Proof of training will contain the duration of training and topics, name of vendorized trainer(s), and list of all attendees.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2024


LIC809 (FAS) - (06/04)
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