210102881-12-14-2023-21-AS-VBEI-CYMRKQ-20231218120553

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 210102881
Report Date: 12/14/2023
Date Signed: 12/14/2023 02:30:07 PM

Unsubstantiated

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 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:	DATE:	12/14/2023
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Staff Member, Nancy Mckee, and Administrator, Tina Camaclang		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Questionable death
Staff neglect resulted in a resident developing multiple pressure injuries
Staff did not meet a resident's hygiene needs and services
Staff overcharged a resident for services not received
Staff did not provide financial statements to authorized representative
Staff did not properly report an incident involving a resident
Facility not kept at comfortable temperature
Facility did not provide proper nutrition as prescribed

INVESTIGATION FINDINGS:

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At approximately 1:15PM, Licensing Program Analyst (LPA) Felias arrived uannnounced to deliver findings for a Complaint Investigation regarding the above allegations and met with Staff Member, Nancy Mckee. Administrator, Tina Camaclang, arrived during visit at approximately 2:05PM.

During the course of the Investigation, the Department requested and reviewed documents, conducted interviews, and made observations.

There is an allegation of Questionable Death. Reporting Party stated that R1 weighed 230lbs when admitted to the facility and weighed less than 80lbs at the time of their passing. Review of R1’s documents stated they were admitted to Hospice on 08/22/2022. R1’s Hospice Records dated 08/24/2022, stated that R1 had increased weakness and appetite and had lost 24lbs since July 2022.

Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

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: 12/14/2023

NARRATIVE

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Continued from LIC9099

Hospice Records dated 02/13/2023, 04/10/2023, 06/12/2023, and 08/14/2023 stated that R1 was observed to have continued loss of appetite. R1’s Death Certificate dated 09/13/2023 indicated their cause of death was unrelated to their weight loss. Based on records reviewed, this allegation is Unsubstantiated.

There is an allegation of Staff neglect resulting in a resident developing multiple pressure injuries. Reporting Party stated that R1 had multiple bedsores and rashes during their stay at the facility. Review of R1’s Hospice Records dated 02/13/2023, stated that on 10/18/2022 a rash was observed on R1’s upper back. Hospice Records stated that the rash had a resolution date of 12/13/2022. Review of Hospice Records dated 04/10/2023 stated in February 2023, R1 was observed to have a Stage 1 pressure ulcer. Hospice Records dated 04/10/2023 stated that R1’s ulcer was observed to have improved due to regular wound care. Hospice Records dated 08/14/2023 stated R1 had a sacral pressure wound. Hospice Records stated that this pressure wound progressed to a Stage 2 ulcer despite R1 receiving optimal wound care. Records also stated that R1 was resistant to repositioning which limited their progression of healing. Trans-Disciplinary Notes dated 02/10/2023, 03/03/2023, 03/17/2023, 03/31/2023, 05/31/2023 indicated that R1 was seen by Hospice to receive treatment for their pressure injuries. Based on records reviewed, this allegation is Unsubstantiated.

There is an allegation that Staff did not meet a resident's hygiene needs and services. Reporting Party stated that R1 had infrequent baths and poor hygiene due to staff refusing to trim their nails and wash their hair. Interview conducted with Facility Staff stated that R1 was provided incontinence care 3-4 times a day and was offered or provided a sponge bath daily. Interview also stated that R1 would sometimes refuse care even when Hospice would visit. Interview also stated that Home Health and Hospice Aides visited approximately 3-4 times per week and that there were no concerns regarding R1’s care at the facility. Interview also stated that R1 would refuse care at times during their visits. Based on interviews conducted and records reviewed, this allegation is Unsubstantiated.

There is an allegation that Staff overcharged a resident for services not received. Reporting Party stated that the Facility charged R1 to pay for the following services: transportation to the hospital and for a podiatrist to cut R1’s toenails. Review of R1’s Admission Agreement states that the “facility will plan, arrange, and/or provide transportation to medical and dental appointments.” The Agreement also states that “assistance in meeting necessary medical and dental needs as follows: will assist resident in calling for medical and dental appointments for necessary transportation.” Interview conducted with Administrator stated that R1 was informed of the charges prior to needing the transportation service. Attempts to contact the Reporting Party for further information were unsuccessful.

Continued on LIC9099C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

LIC9099 (FAS) - (06/04)

Page: 4 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: 12/14/2023

NARRATIVE

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Continued from LIC9099C

Review of the Admissions Agreement states that services such as pedicure and manicures are considered an optional item and service. Interview conducted with Facility Staff stated that for toenails, the podiatrist would come to the facility, and for fingernails, R1 would cut their fingernails themselves, or they would request Hospice would do it. Interview conducted with Hospice Provider stated that Hospice was responsible for providing fingernail care and that a podiatrist would provide toenail services. Based on interviews conducted and records reviewed, this allegation is Unsubstantiated.

There is an allegation that Staff did not provide financial statements to authorized representative. Interview conducted with Administrator stated that the Reporting Party had requested for the financial statements through a legal entity and that the invoices were provided to them. Copies of these invoices were provided to Community Care Licensing. Attempts to contact the Reporting Party for further information were unsuccessful. Based on interviews conducted and records reviewed, this allegation is Unsubstantiated.

There is an allegation that Staff did not properly report an incident involving a resident. Reporting Party stated that Facility agreed to update them on R1's condition when they were rapidly declining in health and that R1 passed away on 09/05/2023. Per Title 22 Regulations – 87211 Reporting Requirements, the Licensee is required to notify the licensing agency and the person responsible for a resident within 7 days for any of the following circumstances: death, serious injury, use of an Automated External Defibrillator, or any incident that threatens their welfare, safety, or health. Community Care Licensing (CCL) received a death report notification for R1 on 09/11/2023 which is within regulation. Based on observations and records reviewed, this allegation is Unsubstantiated.

There is an allegation that Facility is not kept at a comfortable temperature. Per Title 22 Regulations - 87303 Maintenance and Operation, facilities must maintain a comfortable temperature between 68 degrees and 85 degrees Fahrenheit. During visits conducted on 10/27/2022, 1/26/2023, 07/13/2023, 10/31/2023, 12/07/2023, LPA observed that the facility’s thermostat temperatures measured at 68F, 72F, 73F, 69F. Based on these observations, the facility is within regulation and therefore, this allegation is Unsubstantiated.

There is an allegation that Facility did not provide proper nutrition as prescribed. Reporting Party stated that Facility refused to provide Ensure supplemental shakes to R1 since it was not prescribed by their Physician. Hospice Records dated 06/12/2023 stated that R1 had been consuming 1 main meal a day and having Ensure or milk for lunch and dinner. Hospice Records dated 08/14/2023 stated that R1’s meal intake had decreased from 50% of 1 meal to 30% of 1 meal daily. Interviews conducted with facility staff corroborate these Hospice records. Based on interviews conducted and records reviewed, this allegation is Unsubstantiated.

Continued on LIC9099C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

LIC9099 (FAS) - (06/04)

Page: 3 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: 12/14/2023

NARRATIVE

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Continued from LIC9099C

A finding that the complaint is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

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 Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4