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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210102881
Report Date: 12/03/2021
Date Signed: 12/03/2021 10:45:05 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:SCHON HYME REST HOMEFACILITY NUMBER:
210102881
ADMINISTRATOR:TINA CAMACLANGFACILITY TYPE:
740
ADDRESS:25 VILLA AVENUETELEPHONE:
(415) 524-8058
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY:12CENSUS: 8DATE:
12/03/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Volunteer, Gina LongoriaTIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived at Schon Hyme Rest Home unannounced for the purpose of conducting a complaint investigation inspection. Upon arrival, LPA was greeted by Volunteer, Gina Longoria. House Manager, Nancy McKee arrived 15 minutes later.

During the inspection, LPA met volunteer who was working in the kitchen. Upon further review it was determined volunteer did not have the proper fingerprint association to the facility. volunteer explained she just started today. LPA explained that prior to working or volunteering, a fingerprint clearance is required and the individual must be associated to the facility. Volunteer did have a fingerprint clearance but was not associated to the facility. LPA advised house manager to have the volunteer associated to the facility.

An immediate civil penalty for $100.00 was issued today for individual not being associated to this facility as required. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview was conducted and a copy of this report was signed and given to House Manager, Nancy McKee.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021
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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: SCHON HYME REST HOME
FACILITY NUMBER: 210102881
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/03/2021
Section Cited

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87355(e)(2)Criminal Record Clearance-All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: Request transfer of a criminal record clearance as specified in Section 87355
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This requirement was not met. As evidenced by: during today's inspection and verification with CCL Guardian: Volunteer was fingerprint cleared but not associated to this facility as required. This is an immediate risk to the Health & Safety of residents in care.
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POC due date 12/04/2021

An immediate civil penalty for $100.00 was issued for volunteer not being associated to this facility.

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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: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 12/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2021
LIC809 (FAS) - (06/04)
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