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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 210102881
Report Date: 10/31/2023
Date Signed: 10/31/2023 03:16:13 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/06/2023 and conducted by Evaluator Caitlynn Felias
COMPLAINT CONTROL NUMBER: 21-AS-20230906103102
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: 7DATE:
10/31/2023
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Staff Member, Nancy Mckee, and Administrator, Tina CamaclangTIME COMPLETED:
03:25 PM
ALLEGATION(S):
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Staff mishandled a resident's medication while in care
INVESTIGATION FINDINGS:
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At approximately 1:30PM, Licensing Program Analyst (LPA) Felias arrived uannnounced to continue a Complaint Investigation regarding the above allegation and met with Staff Member, Nancy Mckee, and Administrator, Tina Camaclang.

During the course of the investigation, LPA reviewed and requested documents, made observations, and conducted interviews. There is an allegation that Staff mishandled a resident's medication while in care. During visit conducted on 10/31/2023, LPA reviewed 7 of 7 resident medications, their MARs, and their Centrally Stored Medication Log. 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. It was also observed that Resident 6 (R6) had 3 medications being administered. These medications were not reflected in R6's most current physician orders and LPA was unable to locate their prescriptions.
Continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 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.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 21-AS-20230906103102
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
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Continued from LIC9099

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. This allegation is Substantiated. (This deficiency has been cited, see LIC9099D, Regulation 87465(a)(4)).

A finding that the Complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

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), LIC9099D (Deficiency Page), 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: 10/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 21-AS-20230906103102
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
87465(a)(4)
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87465 Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed...plan shall...provide...assistance...(4)The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
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Licensee to submit a self-certification stating they will do the following: Audit all resident medications and ensure that it matches most current physician orders; Conduct In-Service Training reviewing Regulation and medication management; Licensee to submit detailed plan to ensure future compliance. In-Service
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Based on observations made, Licensee did not comply with the section cited above. it was observed that R5, R6, and R7 had medications administered that did not reflect their most current physician orders. This poses an immediate health, safety, and personal risk to residents in care.
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training to include: Date of Training, Training Topics, Job Role, Staff Names and Signatures. Self-certification to be submitted by POC due date of 11/01/2023. Proof of Audit, In-Service training, and detailed plan to be submitted for review and approval by POC due date of 11/10/2023.
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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: 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
LIC9099 (FAS) - (06/04)
Page: 3 of 4