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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210102881
Report Date: 07/21/2022
Date Signed: 07/21/2022 03:44:58 PM


Document Has Been Signed on 07/21/2022 03:44 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:SCHON HYME REST HOMEFACILITY NUMBER:
210102881
ADMINISTRATOR:MENDOZA, CECILEFACILITY TYPE:
740
ADDRESS:25 VILLA AVENUETELEPHONE:
(415) 524-8058
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY:12CENSUS: 10DATE:
07/21/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Care Giver, Gennyfer LaganaTIME COMPLETED:
04:00 PM
NARRATIVE
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At approximately 2:15PM, Licensing Program Analysts (LPAs) Sarangi and Felias arrived unannounced to conduct a Case Management - Non-compliance inspection. Facility is on a Non-Compliance Plan. LPAs met with Care Giver, Gennyfer Lagana, and was granted access into the facility. Administrator, Tina Camaclang, was available by telephone.

LPAs toured the facility with Care Giver, Gennyfe Lagana. During the tour, LPAs observed the facility to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on November 2021 at the time of the inspection. First Aid Kit was found to be appropriate during the inspection. 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 smoke detectors and carbon monoxide detectors were observed and tested during this inspection. Auditory alerts were equipped on the exit door and the balcony door leading to the backyard. Hot water temperature measured within Title 22 acceptable regulation of 105 to 120 degrees in resident’s bathrooms while touring facility. 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. 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 tour of all resident’s bedrooms were conducted, and bedrooms inspected have lighting & appropriate furnishing. Beds are outfitted with Mattress pads as per Title 22 regulations.
LPAs reviewed 5 staff files and observed that documented training was not sufficient to meet regulation. (See photos taken and See LIC 809D)
The following deficiencies were observed (see LIC 9099D) 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 of rights provided to the Care Giver, Gennyfer Lagana.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2022
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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Document Has Been Signed on 07/21/2022 03:44 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/28/2022
Section Cited

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1569.625(b)Staff training. Staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training and shall also include an additional 20 hours annually. This requirement was not met as evidenced by:
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Based on records review, staff currently working at the facility lacked proof of the required annual training and staff hired. This violation is a potential health and safety risk to residents in care.
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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: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2022
LIC809 (FAS) - (06/04)
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