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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005410
Report Date: 11/15/2023
Date Signed: 11/21/2023 03:14:13 PM

Document Has Been Signed on 11/21/2023 03:14 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:SCHUMARD CARE HOMEFACILITY NUMBER:
397005410
ADMINISTRATOR:DIZON, JESSICAFACILITY TYPE:
735
ADDRESS:18268 SCHUMARD OAK ROADTELEPHONE:
(209) 323-5590
CITY:LATHROPSTATE: CAZIP CODE:
95330
CAPACITY: 6CENSUS: 5DATE:
11/15/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Judith Levita and Jessica DizonTIME COMPLETED:
04:30 PM
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Unannounced case management visit made out to this facility on 11/15/2023 by this Licensing Program Analyst (LPA) Charlie Yang who was met by the facility caregiver, Judith Levita, and requested to go ahead and contact the facility designated Administrator to inform him/her that CCL was present at this time.
The facility designated Administrator, Jessica Dizon, arrived later on to this facility.
A brief interview was conducted with the facility designated Administrator Jessica Dizon.
Current census was 5 residents, of which one, was a new move-in while this LPA was present.
The purpose of this case management visit was to follow up on an incident that was reported into CCL in regards to a resident R1.

The following forms and documents were requested solely for resident R1 to be copied and submitted into CCL for review by this LPA:
  • LIC 602

  • LIC 604

  • Any, and all, LIC 624s related to R1 since admission

  • Needs and Appraisal

  • Most recent IPP

  • ID/Emergency Contact

Further review of the forms and documents will be conducted upon receipt by this LPA. Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2023
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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