210102881-7-13-2023-21-AS-CFES-CTPRWT-20230713132339

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 210102881
Report Date: 07/13/2023
Date Signed: 07/13/2023 01:23:44 PM

Document Has Been Signed on 07/13/2023 01:23 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 HOME		FACILITY NUMBER:	210102881
ADMINISTRATOR:	ALBERTINA CAMACIANG		FACILITY TYPE:	740
ADDRESS:	25 VILLA AVENUE		TELEPHONE:	(415) 524-8058
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94901
CAPACITY:	12	CENSUS: 9	DATE:	07/13/2023
TYPE OF VISIT:	Case Management - Legal/Non-compliance	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Staff Member, Nancy Mckee, and Administrator, Tina Camaclang		TIME COMPLETED:	01:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At approximately 9:50AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Non Compliance Visit and met with Staff Member, Nancy Mckee. Administrator,Tina Camaclang, was available via telephone and arrived later during visit at approximately 12:15PM. Facility serves residents with dementia and has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance for 3 ambulatory and 9 non-ambulatory residents for a total capacity of 12 residents. Facility has an approved hospice waiver for 3 individuals. Upon arrival, LPA was informed that there were currently 9 residents in care and 3 staff members on site. LPA conducted a walk-through of the facility and observed the following: Facility was clean and at a comfortable temperature with all exits free from obstruction. Auditory alerts on the exit door and the balcony door were observed to be operational. There was a sufficient supply of perishable and non-perishable foods. 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: All staff present were eligible and cleared to work in facility Dining Room temperature was observed to be at 73 degrees. Hot water temperatures for all sinks in facility were within Title 22 regulations of 105 to 120 degrees Fahrenheit. Facility's Central Stored Medication and Medication Administration Record (MAR) for 5 of 9 residents were observed to be secure. Administrator, Tina Clamaclang, has current Administrator paperwork. Certificate (6010282740) expires 2/16/2024. Facility's fire extinguishers were last inspected December 2022. Continued on LIC809C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023

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: 07/13/2023

NARRATIVE

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Continued from LIC809

During visit, LPA reviewed staff training and observed that there was no paperwork available for Staff Member 1 (S1) apart from their background clearance documentation. Per conversation with S1, they did not receive any training when they began their employment. Per conversation with Administrator, S1's training and 2023 Annual Training documentation for all staff is currently off-site at their place of residence. This deficiency has been cited (See LIC809D). Per Title 22 Regulations and Health and Safety Code, all employees who assist Residents with Activities of Daily Living (ADLs) are to receive 40 hours of Initial Training and an additional 20 hours of Annual Training.

Administrator stated that they will submit the required documentation for S1 along with the current 2023 Annual Training documentation to CCL.

LPA discussed Initial and Annual Training Requirements for all Staff that provide Direct Care to Residents with Administrator.

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 Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/13/2023 01:23 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: 07/13/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/23/2023 Section Cited CCR 87411(c)	1 2 3 4 5 6 7	87411 Personnel Requirements - General: (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. This requirement was not met as evidenced by: Based on records	1 2 3 4 5 6 7	Licensee to submit Proof that Required Initial Training for S1 has been conducted. Current 2023 Annual Training completed for All Staff to also be submitted to CCL for review and approval by POC due date of 07/23/2023.
	8 9 10 11 12 13 14	reviewed and interviews conducted, Licensee did not comply with the section cited above because S1 was missing Initial Training documentation. 2023 Annual Training for all staff was unable to be reviewed and verified. This poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023

LIC809 (FAS) - (06/04)

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