210102881-10-31-2023-21-AS-CFES-CX5U22-20231031151114

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 210102881
Report Date: 10/31/2023
Date Signed: 10/31/2023 03:11:20 PM

Document Has Been Signed on 10/31/2023 03:11 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: 7	DATE:	10/31/2023
TYPE OF VISIT:	Case Management - Legal/Non-compliance	UNANNOUNCED	TIME BEGAN:	09:30 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 9:30AM, 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, arrived later during visit at approximately 10:25AM. 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 6 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. 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 observed that there was a walker and wheelchair obstructing the exit to a resident's balcony. This exit was observed to not be an emergency exit. LPA and Administrator discussed the importance of keeping doors unobstructed by obstacles in the event of an emergency. During visit, LPA also observed the residents participating in a singing activity presented by Hospice. LPA made the following observations: All staff present were background cleared and associated to the facility per regulation Dining Room temperature was observed to be at 69 degrees Administrator, Tina Clamaclang, has current Administrator paperwork. Certificate (6010282740) expires 2/16/2024. Facility's fire extinguishers were last inspected December 2022. Hot water temperatures for facility sinks were observed to be at 117.6F, 120.3F, 126.6F, 123.6F, 123.6F, 118.9F, and 122.0F (This deficiency has been cited, see Regulation 87303(e)(2)). Administrator immediately lowered water heater during visit. 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: 10/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

Document Has Been Signed on 10/31/2023 03:11 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: 10/31/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/01/2023 Section Cited CCR 87303(e)(2)	1 2 3 4 5 6 7	87303 Maintenance and Operation (e)Water supplies...shall be maintained... (2) Faucets used by residents...Hot water temperature controls shall be maintained...of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee to ensure that hot water temperature stays within Title 22 Regulations of not less than 105 degree F and not more than 120 degree F. Licensee to submit a self-certification stating they will do the following log:
	8 9 10 11 12 13 14	Based on observations made, Licensee did not comply with the section cited above. Sinks were observed with the following temperatures 117.6F, 120.3F, 126.6F, 123.6F, 123.6F, 118.9F, and 122.0F. This poses an immediate health, safety, and personal risk to residents in care.	8 9 10 11 12 13 14	Facility to adjust temperature and submit a 10 day log checking water twice a day by POC due date of 11/10/2023 in order to clear this citation. Note: During visit LPA observed Administrator adjusted the water heater temperature.
	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: 10/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: 10/31/2023

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
26
27
28
29
30
31
32

Continued from LIC809

LPA reviewed 7 of 7 resident medications, their Medication Administration Records (MARs), and their Centrally Stored Medication Log. During review, it was observed that Resident 5 (R5) had a medication dosage change. This change was not reflected in R5's most current physician orders and LPA was unable to locate the new prescription. Resident 6 (R6) has 3 medications being administered. These medications were not reflected in R6's most current physician orders and LPA was unable to locate their prescriptions. Resident 7 (R7) has 2 medications being administered. Review of R7's physician report did not reflect medications being administered. It was observed that one medication to be administered is not at the facility. LPA was also unable to locate R7's MAR.

Administrator immediately contacted all resident's physicians for medication clarification.*This deficiency for medication mismanagement has been cited under Regulation 87465(a)(4). Deficiency has been cited under Complaint 21-AS-20230906103102, LIC9099D, Visit conducted 10/31/2023.*

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, LIC811 (Confidential Names), LIC809D (Deficiency Page), 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: 10/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3