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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210102881
Report Date: 01/31/2024
Date Signed: 01/31/2024 01:46:11 PM


Document Has Been Signed on 01/31/2024 01:46 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 HOMEFACILITY NUMBER:
210102881
ADMINISTRATOR:ALBERTINA CAMACIANGFACILITY TYPE:
740
ADDRESS:25 VILLA AVENUETELEPHONE:
(415) 524-8058
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY:12CENSUS: DATE:
01/31/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Staff Member, Nancy Mckee, and Administrator, Tina CamaclangTIME COMPLETED:
02:00 PM
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At approximately 9:05AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Legal/Non-Compliance visit and met with Staff Member, Nancy Mckee. Administrator, Tina Camaclang, arrived later during visit at approximately 10:15AM. 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 7 residents in care and 2 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 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 68 degrees
  • Administrator, Tina Clamaclang, has current Administrator paperwork. Certificate (6010282740) expires 2/16/2024.
  • Facility's fire extinguishers were last inspected December 2022 (this deficiency has been cited, see LIC809D, Regulation 87202(a)). Administrator immediately contacted vendor to have fire extinguishers inspected. Administrator understands that fire extinguishers need to be inspected annually per Title 22 Regulations.
  • Hot water temperatures for facility sinks were observed to be at 105.2F, 105.0F, 104.9F, 101.4F, 102.5F, and 102.3F. One sink was unable to be checked for temperature due to the pipe being broken. (These deficiencies have been cited, see LIC809D, Regulation 87303(e)(2), and 87203(e)(6)). Administrator immediately raised facility's water heater during visit and contacted a vendor to have the pipe fixed.
  • LPA reviewed 3 of 7 resident medications, their Medication Administration Records (MARs), and their Centrally Stored Medication Log.

Continued on LIC809C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2024
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 4


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: 01/31/2024
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Continued from LIC809

During review, LPA observed that one resident's current physician medication orders did not match facility's central storage record, and therefore the medication was not administering as prescribed (this deficiency has been cited, see LIC809D, Regulation 87465(a)(4)).

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.

***Immediate civil penalties in the total amount of $1,000.00 has been issued for being out of compliance with fire clearance Regulation 87202(a) and for repeat violations of Regulations 87202(e)(2) and Regulation 87465(a)(4) more than once in a 12 month period.*** (See LIC421IM, and LIC421FC)

Exit interview conducted. Copy of report, LIC809D, LIC421IM, LIC421FC, Plan of Corrections, and Appeal Rights discussed, reviewed, 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: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/31/2024 01:46 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: 01/31/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/01/2024
Section Cited
CCR
87202(a)

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87202 Fire Clearance:(a)All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal...This requirement was not met as evidenced by: Based on observations made,
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Licensee to contact vendor to have fire extinguishers serviced by POC due date 02/01/2024. Licensee contacted vendor during LPA's visit. Licensee to submit a copy of invoice/receipt and pictures of newly dated tags to Department by POC date of 02/10/2024.
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the Licensee did not comply with the section cited above. Licensee did not ensure that fire extinguishers were serviced or inspected annually as required. Facility contacted vendor and scheduled inspection during visit. This poses an immediate health and safety risk to residents in care.
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Type A
02/01/2024
Section Cited
CCR87303(e)(2)

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87303 Maintenance and Operation:(e)Water supplies and plumbing fixtures shall be maintained as follows:(2) Faucets...shall deliver hot water...temperature...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 was not
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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: Facility to adjust temperature and submit a 10 day log checking water twice a day
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met as evidenced by: based on observations made, the Licensee did not comply with the section cited above. Water temperatures for 5 of 7 sinks were less than 105F. This poses an immediate health and safety risk to residents in care.
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by POC due date of 02/01/2024. Log to be submitted to CCL by POC due date of 02/10/2024. Note: During visit LPA observed Administrator adjusted the water heater temperature.
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: 01/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 01/31/2024 01:46 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: 01/31/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/01/2024
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...(4)The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: based on observations made and records reviewed,
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Licensee to submit a self-certification stating the following will be completed: Outside vendor or medical professional to audit all resident medications and conduct In-Service Training for medication and central storage records. Licensee to submit detailed plan to ensure future compliance. In-Service
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the Licensee did not comply with the section cited above. It was observed that one resident's current medication list did not match the facility central storage record and medication was administered incorrectly. This poses an immediate health and safety risk to residents in care.
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training to include: Date, Training Topics, Job Role, Staff Names and Signatures. Self-certification to be submitted by POC due date 02/01/2024. Proof of In-Service training to be submitted for review and approval by POC due date of 02/10/2024.
Type B
02/10/2024
Section Cited
CCR87203(e)(6)

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87303 Maintenance and Operation:(e) Water supplies and plumbing fixtures shall be maintained as follows:(6)Toilet, handwashing and bathing facilities shall be maintained in operating condition...This requirement was not met as evidenced by: based on observations made, the Licensee did not
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Licensee to contact vendor/plumber to have sink fixed. Licensee contacted vendor during LPA's visit. Licensee to submit a copy of invoice/receipt and pictures of newly fixed sink to Department by POC date of 02/10/2024.
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comply with the section cited above. It was observed that 1 of 7 sinks were inoperable as the pipes under the sink were broken. This poses a potential health and safety risk ro residents in care.
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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: 01/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4