210102881-6-11-2021-21-AS-FSAI-C3VVGZ-20210611162622

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 210102881
Report Date: 06/11/2021
Date Signed: 06/11/2021 04:27:39 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME:	SCHON HYME REST HOME		FACILITY NUMBER:	210102881
ADMINISTRATOR:	TINA CAMACLANG		FACILITY TYPE:	740
ADDRESS:	25 VILLA AVENUE		TELEPHONE:	(415) 524-8058
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94901
CAPACITY:	12	CENSUS: 10	DATE:	06/11/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:55 PM
MET WITH:	Care Staff Worker, Nancy Deleon		TIME COMPLETED:	04:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	License Program Analysts (LPAs) Farhaan Sarangi and Erik Gonzalez-Campos arrived unannounced to conduct an Required – 1 year visit of the facility. LPAs were welcomed by Care Staff Worker, Nancy Deleon. There is a total of 10 residents. However, during the entrace, LPAs observed a Care Staff Worker not having a facial covering. There are some residents with Dementia and some residents on Hospice. LPAs toured the facility on June 11, 2021 at 02:00 PM with Care Staff Worker, Nancy Deleon. During the tour LPAs observed the facility to be clean and at a comfortable temperature with all exits free from obstruction. Exits were free from obstructions at the time of the visit. LPAs observed auditory device turned off at the backdoor leading to the red patio. Fire Extinguisher was found to be last charged on November 2020 at the time of the visit. Facility smoke detectors are hard wired and sound directly to the fire station. There are emergency lights in many of the fixtures in the common areas of the facility that come on should a power outage occurs. Facility has single smoke detectors through out of the facility except for one resident bedroom (Photo attached). Hot water temperature measured within Title 22 acceptable regulation of 105 to 120 degrees in resident’s bathrooms while touring facility on June 11, 2021. Facility serves residents with dementia and has special care plan of operation and programming. There was a sufficient supply of perishable and non-perishable foods. LPAs observed a large purple soap located underneath the kitchen sink. Medications were centrally stored in a locked medication cabinet between the kitchen and resident’s bedroom in the facility. There was a supply of cleaners, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. A sample tour of resident’s bedrooms was conducted, and bedrooms inspected have lighting & appropriate furnishing. Beds were outfitted with mattress pads with the exception of one resident room as required by Title 22 Regulations. (Report continued on LIC 809C)

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021

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
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: SCHON HYME REST HOME	FACILITY NUMBER: 210102881
	VISIT DATE: 06/11/2021

NARRATIVE

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LPAs advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Disaster Drills were conducted May 2021. LPAs reviewed the Mitigation Plan with the Facility Administrator. LPAs requested an updated Emergency Disaster plan to be forwarded to the Regional Office.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview was conducted and a copy of this report along with appeal rights were emailed to the Facilities Administrator, Tina Camaclang.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021

LIC809 (FAS) - (06/04)

Page: 3 of 10

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: SCHON HYME REST HOME	FACILITY NUMBER: 210102881
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/11/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.311

Regulations

Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above due to having one Carbon Monoxide detector missing from a bedroom which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/18/2021
	Plan of Correction
1 2 3 4	Facility will install the Carbon Monoxide detector and provide proof of that installation. LPAs observed Administrator installing Carbon Monoxide detector and thus have fulfilled the Plan of Correction.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021

LIC809 (FAS) - (06/04)

Page: 10 of 10

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: SCHON HYME REST HOME	FACILITY NUMBER: 210102881
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/11/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(j)

The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the facility did not comply with the section cited above in 1 auditory alarm being turned off which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/12/2021
	Plan of Correction
1 2 3 4

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021

LIC809 (FAS) - (06/04)

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