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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210102881
Report Date: 08/26/2021
Date Signed: 08/26/2021 12:25:36 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 HOMEFACILITY NUMBER:
210102881
ADMINISTRATOR:TINA CAMACLANGFACILITY TYPE:
740
ADDRESS:25 VILLA AVENUETELEPHONE:
(415) 524-8058
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY:12CENSUS: 10DATE:
08/26/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator, Tina CamaclangTIME COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived at Schon Hyme Rest Home for the purpose of conducting an unannounced Case Management-Health Checks of the facility. LPA was greeted at the door by Administrator, Tina Camaclang. LPA was granted access into the home. Upon entry, LPA observed temperature being taken and a logbook. LPA observed staff wearing masks and adhering to the Mask Mandate.

LPA toured the facility kitchen and found that there were no disinfectants, cleaning solutions and poisons present. LPA observed where the hazardous items were locked and inaccessible to residents in care. LPA observed the smoke detector in the room that was tested and operable during this tour. Auditory alarms were present and operable during today's Case Management-Health Checks inspection.

No deficiencies were observed or cited during today's Case Management-Health Checks inspection. Exit interview was conducted and a copy of this report was emailed to the facility Administrator, Tina Camaclang.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021
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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