210102881-5-4-2022-21-AS-HDBI-CEGVLS-20220516163226

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 210102881
Report Date: 05/04/2022
Date Signed: 05/04/2022 10:21:34 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/25/2022 and conducted by Evaluator Farhaan Sarangi

COMPLAINT CONTROL NUMBER: 21-AS-20220425143004

FACILITY NAME:	SCHON HYME REST HOME		FACILITY NUMBER:	210102881
ADMINISTRATOR:	MENDOZA, CECILE		FACILITY TYPE:	740
ADDRESS:	25 VILLA AVENUE		TELEPHONE:	(415) 524-8058
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94901
CAPACITY:	12	CENSUS: 8	DATE:	05/04/2022
		UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Staff Member #1, Tina Camaclang		TIME COMPLETED:	10:40 AM

ALLEGATION(S):

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Staff yell at residents
Admissions agreement and Personal Rights were not signed or given to the resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Farhaan Sarangi arrived at Schon Hyme Rest Home for the purpose of delivering complaint findings. Also participating on the delivery of complaint findings is County of Marin, Division of Aging and Adult Services, Long Term Care Ombudsman (LTCO), Elein Phipps. LPA was met at the door by Staff Member #1, Tina Camaclang and was granted access into the facility.

During the course of the investigation, LPA interviewed staff and various outside parties. Various documents were also reviewed at the facility on April 29, 2022 including Admission Agreements, Personal Rights forms and Reappraisals/Needs and Services Plans.

Complaint alleges that Staff yell at residents. Based on interviews with staff, residents and witnesses on April 29, 2022, LPA learned that the former staff member was yelling at residents in care. Facility did terminate the staff member that was yelling at residents in care. (Report continued on LIC 9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20220425143004

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: SCHON HYME REST HOME	FACILITY NUMBER: 210102881
	VISIT DATE: 05/04/2022

NARRATIVE

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Although the facility took action by terminating the former staff member, there was enough evidence to prove that the former staff member did yell at the residents and it did occur at the facility (See LIC 9099D).

Complaint alleges that Admissions agreement and Personal Rights were not signed or given to the resident. LPA reviewed the Admission Agreements, Personal Rights forms and Reappraisals/Needs and Services Plan for all residents in care. LPA learned that 1 out of 8 Admission Agreements were not signed or dated by the Responsible Party or the Resident. LPA also observed that Personal Rights were signed by 7 out of 8 residents and their Responsible Parties (See LIC 9099D). In addition, LPA observed that 5 of 8 residents Reappraisals were not signed by the Responsible Party or the Resident (See LIC 9102).

Based upon the statement made by the Administrator and the review of resident records, the preponderance of evidence standard has been met regarding Staff yelling at residents and admission agreement and personal rights were not signed or given to the resident. Therefore, the above allegations are found to be SUBSTANTIATED. The following deficiencies were observed and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted and appeal rights were provided.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20220425143004

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: SCHON HYME REST HOME	FACILITY NUMBER: 210102881
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/04/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/06/2022 Section Cited CCR 87468.1(a)(3)	1 2 3 4 5 6 7	87468.1(a)(3) Personal Rights of Residents in all facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.	1 2 3 4 5 6 7	POC will consist of staff training regarding Personal Rights and review of regulation. Facility shall submit a Proof of Correction and plan for future compliance to CCL by POC date, May 6, 2022.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on interviews with staff, residents and witnesses on April 29, 2022, it was disclosed that the former staff member yelled at residents in care which poses an immediate health, safety and personal rights risk to the residents in care.	8 9 10 11 12 13 14	In addition, facility will provide proof of termination documents to LPA’s attention by the due date.
Type B 05/11/2022 Section Cited CCR 87507(c)	1 2 3 4 5 6 7	87507(c): Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident’s representative, if any, and the licensee or the licensee’s designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above.	1 2 3 4 5 6 7	POC will consist of staff training regarding intake, assessment and admission agreements. In addition, LPA will need proof that ALL Admission agreements, Reappraisal/Needs and Services documents and Personal Rights documents are signed and kept in the resident file(s).
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based off observation of resident records review on April 29, 2022, LPA observed 1 out of 8 Admission Agreements were not signed or dated by the Responsible Party or the Resident which presents a potential health and safety risk to residents in care.	8 9 10 11 12 13 14	Facility shall submit a Proof of Correction and plan for future compliance to CCL by POC date, May 11, 2022

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: 05/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022

LIC9099 (FAS) - (06/04)

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