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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210102881
Report Date: 10/27/2022
Date Signed: 10/27/2022 04:43:30 PM


Document Has Been Signed on 10/27/2022 04:43 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:ALBERTINA CAMACIANGFACILITY TYPE:
740
ADDRESS:25 VILLA AVENUETELEPHONE:
(415) 524-8058
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY:12CENSUS: DATE:
10/27/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator, Tina CamaclangTIME COMPLETED:
05:00 PM
NARRATIVE
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At approximately 9:00AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Non-Compliance Inspection, and met with caregiver, Nancy Mckee (Deleon). Administrator, Tina Camaclang, arrived later during the visit. Facility is on a Non-Compliance Plan.

Upon arrival, LPA had their temperature taken. LPA observed all staff members wearing a mask. LPA conducted a walk-through of the facility and observed the following: LPA observed the facility to be clean and at a comfortable temperature with all exits free from obstruction. Facility serves residents with dementia and has a dementia care plan of operation and programming. Auditory alerts were equipped on the exit door and the balcony door leading to the backyard. There was a sufficient supply of perishable and non-perishable foods. Medications were centrally stored in a locked medication cabinet between the kitchen and a 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.

LPA reviewed the following:
  • Hot water temperatures for 3 of 5 sinks were within Title 22 regulations of 105 to 120 degrees Fahrenheit. 2 of 5 sinks were found to be out of range at 122 degrees Fahrenheit.
  • Dining Room temperature was observed to be at 68 degrees.
  • Facility's Central Stored Medication and Medication Administration Record (MAR) for 3 of 6 residents was reviewed
  • All staff present were eligible and cleared to work in facility
  • Administrator, Tina Clamaclang, had current administrator paperwork
  • All staff were shown to have at least 20 hours of training completed for 2022; First Aid and/or CPR training also observed to be in staff files.


Continued on LIC-809C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2022
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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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
VISIT DATE: 10/27/2022
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Continued from LIC-809

During visit, LPA observed a visitor at approximately 12:30PM walk into the facility, through the main dining area and to the outdoor visitation area without being screened for COVID-19. LPA ensured that staff took visitor's temperature and that it was logged appropriately.

Fire Extinguishers were found to be last charged on November 2021. There are emergency lights in many of the fixtures in the common areas of the facility that come on should a power outage occurs.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC-809D, Plan of Corrections, and Appeal Rights discussed and provided to Administrator. 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: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 10/27/2022 04:43 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: 10/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/28/2022
Section Cited

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87303 Maintenance and Operation (e)Water supplies...shall be maintained... (2) Faucets used by residents...Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
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 This requirement is not met as evidenced by: Based on Thermometer readings, Licensee did not comply with the section cited above where 2 of 5 sinks showed a hot water temperature of 122.0F.
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 Facility to adjust temperature and submit a 7 day log by POC due date of 11/04/2022 in order to clear this citation.
Note: During visit LPA observed Administrator adjust the water.
Type B
10/28/2022
Section Cited

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87705 Care of Persons with Dementia(c) Licensees...shall be responsible the following:(5)Each resident...shall have an annual medical assessment...a reappraisal...a reassessment...dementia care needs.(A)When any medical assessment, appraisal, or observation indicates...care needs have changed...changes shall be made in the care
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and supervision provided to that resident. This requirement is not met as evidenced by: Based on File Review and Interviews conducted, Licensee did not ensure that Resident's Physician's Report was updated as needed. This poses a potential health, safety, and personal risk to residents in care.
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Date of Training, Training Topics, Job Role, Staff Names and Signatures by POC due date Friday, 11/11/2022. Deficiency to be cleared upon LPA review and approval.
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: 10/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2022
LIC809 (FAS) - (06/04)
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