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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210102881
Report Date: 08/12/2022
Date Signed: 08/12/2022 03:44:13 PM


Document Has Been Signed on 08/12/2022 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:
08/12/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:House Manager, Nancy MckeeTIME COMPLETED:
04:00 PM
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At approximately 2:45PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case-Management Visit and met with House Manager, Nancy Mckee. Administrator, Tina Camaclang was available by telephone. The purpose of the visit is to request and obtain documents.

LPA will follow up with Administrator as the records were not available during today's visit.

No deficiencies cited during visit.

'Exit interview conducted. Copy of report discussed and provided to House Manager. Signature on form confirms receipt of documents.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 08/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2022
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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