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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005410
Report Date: 07/18/2024
Date Signed: 07/19/2024 12:13:32 PM

Document Has Been Signed on 07/19/2024 12:13 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:
07/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Jessica DizonTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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Unannounced Annual Licensing visit made out to this facility on 07/18/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Jessica Dizon, at this time. A brief interview was conducted with the facility designated Administrator at this time.
It was learned that this facility was vendorized to be able to accept and retain up to (6) Level 4I residents at any given time.
This facility is licensed to serve up to (6) Ambulatory only residents at any given time.
Current census was 6 residents, of which (2) of them, were out of the facility at this time.
Tour of this facility was conducted.
A tour of the facility kitchen area was conducted. Drawers and cabinets were opened and the items enclosed were reviewed at this time. Drawers housing knives and sharps were observed to be locked and made inaccessible to the residents at this time.
Cleaning agents, bleach, and other supplies were observed to be locked and made inaccessible to the residents at this time.
A review of the facility food supply was conducted. A review of the facility's 2-day perishable foods and 7-day nonperishable foods was conducted to make sure that there were sufficient quantities on hand at all times.
Medication cabinet, located in the kitchen closet, was reviewed. Policies and procedures involving handling, dispensing, and documentation of the resident medications were discussed with the facility designated staff members at this time. A review of the facility Medication Administration Record and dispensing log was conducted.
Medication cabinet was observed to be locked and made inaccessible to the residents at this time.
Living room, dining area, and all other areas intended for resident use were observed to furnished and maintained in compliance at this time and able to meet the needs of the residents.
A tour of the resident bedrooms was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SCHUMARD CARE HOME
FACILITY NUMBER: 397005410
VISIT DATE: 07/18/2024
NARRATIVE
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A tour of the resident restrooms was conducted.
Hot water temperatures were taken to make sure that they measured within the allowed range of 105-120 degrees at all times.
Laundry area, located on the second floor, was toured. Cleaning supplies, detergents, and bleach were observed to be locked and made inaccessible to the residents at this time.
Linen closet was reviewed. Bed sheets, linens, and towels were observed to be sufficient and able to meet the needs of the residents at this time.
A tour of the garage area was conducted.
First aid kits were observed to be present and contained all of the required components at this time.
Fire extinguishers were observed to be placed on the first and second floors of this facility and were recently reviewed on 03/02/2024 by the local fire extinguisher company, Nor-Cal Fire Inc., and observed to be in compliance at this time.
A tour of the exterior grounds for this facility was conducted. A review of the facility perimeter fence, side gates, and exits was conducted.

A review of (6) facility resident files was conducted and noted on the following LIC 858.
A review of (5) facility staff files was conducted and noted on the following LIC 859.

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

Appeal rights were reviewed and a copy was printed and given to the facility designated Administrator at this time.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 07/19/2024 12:13 PM - It Cannot Be Edited


Created By: Charlie Yang On 07/18/2024 at 12:50 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: 07/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in [1] out of [5] facility personnel files did not have a proper TB clearance or cleared chest x-ray which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/19/2024
Plan of Correction
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The facility designated Administrator stated that all facility personnel records will be reviewed and updated to make sure that proper TB clearances/Cleared Chest X-Rays have been granted by a licensed medical professional at all times. A statement of correction, along with updated TB clearances/cleared Chest X-rays for all facility staff, will be completed and submitted into CCL by the due date of 07/19/2024.
Type A
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in [2] out of [5] facility resident files did not have updated and completed First Aid training at all times which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/19/2024
Plan of Correction
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The facility designated Administrator stated that all facility personnel records will be reviewed and updated to make sure that proper updated First Aid Training will be complete and available for review at all times. A statement of correction, along with updated First Aid Training for all facility staff, will be completed and submitted into CCL by the due date of 07/19/2024.
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: 07/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 07/19/2024 12:13 PM - It Cannot Be Edited


Created By: Charlie Yang On 07/18/2024 at 12:50 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: 07/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that window screens were missing from the sliding glass door. In addition, items such as the broken stairway railing rods and resident bedroom flooring needed to be addressed and repaired/replaced which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2024
Plan of Correction
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The facility designated Administrator stated that the stairway railing rods will be reviewed and repaired/replaced. Also the resident bedroom flooring will be reviewed and updated with the proper repair/replacement needs. All window screens will be reviewed and repaired/replaced as needed. A statement of correction, along with updated photos of the items requested to be repaired/replaced, will be completed and submitted into CCL by the due date of 07/25/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 07/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2024


LIC809 (FAS) - (06/04)
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