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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210102881
Report Date: 11/14/2022
Date Signed: 11/14/2022 03:18:24 PM


Document Has Been Signed on 11/14/2022 03:18 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: 9DATE:
11/14/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Staff Member, Nancy MckeeTIME COMPLETED:
03:30 PM
NARRATIVE
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At approximately 1:30PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case-Management - Deficiencies Visit and met with Nancy Mckee. Administrator, Tina Camaclang was available via telephone. Administrator gave permission for staff member to sign documents in their absence. Facility is on a Non-Compliance Plan.

LPA conducted a walk-though of the facility and tested the facility's 5 sinks. All were within the appropriate range of 105 degrees and 120 degrees Fahrenheit.

During visit conducted on 10/27/2022, LPA reviewed 3 resident files and medication records and found that the centrally stored medications did not match resident medications or medication lists. LPA and Administrator discussed the importance of having updated medical records to verify medications being administered.

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: 11/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2022
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 11/14/2022 03:18 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: 11/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/15/2022
Section Cited

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(h) The following requirements shall apply to medications which are centrally stored:
(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year...This requirement is not met as evidenced by: Based on Records and Medication Review
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Licensee failed to maintain an updated centrally stored medication record for 3 of 9 residents. Medications reviewed including not having discontinue orders or physician orders for some medications. This poses an immediate health and safety risk to residents in care.
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POC due date of 12/2/2022.

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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: 11/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2022
LIC809 (FAS) - (06/04)
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