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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210102881
Report Date: 01/26/2023
Date Signed: 01/26/2023 02:34:53 PM


Document Has Been Signed on 01/26/2023 02:34 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: 8DATE:
01/26/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Administrator, Tina CamaclangTIME COMPLETED:
02:45 PM
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At approximately 11:10AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Non-Compliance Inspection, and met with Administrator, Tina Camaclang. Facility is on a Non-Compliance Plan.

Upon arrival, LPA had their temperature taken and observed that the facility's visitor sheet was current. LPA observed all staff members and visitors 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 showers.

LPA reviewed the following:
  • Hot water temperatures for all sinks in facility were within Title 22 regulations of 105 to 120 degrees Fahrenheit.
  • Dining Room temperature was observed to be at 72 degrees.
  • Facility's Central Stored Medication and Medication Administration Record (MAR) for 4 of 8 residents were reviewed
  • All staff present were eligible and cleared to work in facility
  • Administrator, Tina Clamaclang, had current administrator paperwork. Certificate expires 2/16/2024.
  • All staff were shown to have at least 20 hours of training completed for 2022; Current First Aid and/or CPR training was also observed 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: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2023
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: 01/26/2023
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Continued from LIC 809

Fire Extinguishers were observed to be last charged December 2022. There are emergency lights in many of the fixtures in the common areas of the facility that come on should a power outage occurs.

LPA and Administrator discussed medication review and records.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report 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: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023
LIC809 (FAS) - (06/04)
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