210102881-4-22-2024-21-AS-JFLO-D4KVCW-20240422161949

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 210102881
Report Date: 04/22/2024
Date Signed: 04/22/2024 04:19:57 PM

Document Has Been Signed on 04/22/2024 04:19 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
SANTA ROSA RO, 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: 4	DATE:	04/22/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:50 PM
MET WITH:	Albertina Camaclang, Administrator		TIME COMPLETED:	04:30 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 12:50PM, Licensing Program Analysts (LPAs) Florio and Felias arrived unannounced to conduct a Required 1-year visit and met with staff member Nancy McKee, who is a designated respresentative. Administrator, Tina Camaclang was contacted via telephone and arrived one hour later. 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. Facility is currently on a Non-Compliance Plan. Upon arrival, LPAs were informed that there are currently 4 residents in care and 3 staff members on-site. At approximately 1:00PM, LPAs reviewed Facility Staff Roster with Administrator and found that all staff members on site were background cleared and associated to the facility per regulation. LPAs 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. LPAs observed an insufficient supply of perishable and non-perishable foods. LPAs discussed the importance of plenty of fresh fruits and vegetables being available to residents in care and one weeks worth of nonperishable and dried goods per regulation (this deficiency has been cited, see LIC809D, regulation 87555(a)). There was a supply of fresh linens, 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. LPAs conducted interviews with two residents, who report a lack of activities occurring regularly within the facility (this deficiency has been cited, see LIC809D, regulation 87219(a)(1)). LPAs discussed with Administrator the importance of regular stimulating activity for residents in care per regulation. As part of their Non-Compliance Plan, LPAs 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 72 degrees. Continued on LIC809C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Julie Florio	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2024

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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: SCHON HYME REST HOME	FACILITY NUMBER: 210102881
	VISIT DATE: 04/22/2024

NARRATIVE

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Continued from LIC809

Administrator Certificate for Tina Camaclang (6010282740) expired 2/16/2024. Per review of Department website, Administrator is not on the pending list, but was able to provide proof of completed Administrator renewal training dated December 2023. Administrator agreed to submit proof of receipt and documents showing that their renewal application has been received by CCL.
Facility's fire extinguishers were last inspected March 18, 2024.
Hot water temperatures for facility sinks were observed to be at 107.2F, 106.0F, 108.1F, 109.2F, 110.4F, and 109.4F.
LPAs observed Comet cleaning powder with bleach located under the kitchen sink which was unlocked and accessible to residents in care (this deficiency has been cited, see LIC809D, regulation 87705(f)(2)). LIcensee removed the Comet immediately.

During walk-through, LPAs observed that a small room located in the kitchen was being utilized as a bedroom for a staff member. Per conversation with staff member, this room has been used as a bedroom since they started in November 2023. LPAs obtained pictures of the bedroom. LPAs observation of the room shows a small bed, personal items, an extension cord, and an electric water kettle. Review of facility sketch does not indicate this room as a staff room, or any type of living space. LPAs discussed that the Licensee submit an updated facility sketch to include the bedroom so the Department can request a new fire clearance.

LPAs also discussed the process of applying for a new license with Administrator. On 04/01/2024, the Regional Office received notice from the Licensee that they intend to retire on July 1, 2024. LPA advised Licensee and Administrator on the process of closing a facility including the eviction process per Title 22 Regulations. Licensee understands that they are responsible for continuing to provide care to the facility's current residents if Administrator is unable to receive their License in the time frame indicated. Per conversation with the Administrator, they are currently in the process of applying for their license. Administrator to provide an update to Community Care Licensing by 05/02/2024.

LPAs unable to complete Annual Inspection. Annual visit to be continued on a later date.

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, LIC809D, Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Julie Florio	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/22/2024 04:19 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
SANTA ROSA RO, 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: 04/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPAs observed Comet cleaning powder with bleach located under the kitchen sink which was unlocked and accessible to residents. This poses an immediate health, safety or personal rights risk to residents in care.
	POC Due Date: 04/23/2024
	Plan of Correction
1 2 3 4	LIcensee removed the Comet immediately and assured LPAs the chemicals will be stored in a locked storage closet moving forward. Licensee to submit a self-certification acknowledging understanding and agreement of future compliance by POC due date of 4/23/24. LIcensee to submit proof of staff training reviewing the above cited regulation by 05/02/2024 for review and approval.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Julie Florio	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/22/2024 04:19 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
SANTA ROSA RO, 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: 04/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87219(a)(1)

Planned Activities

(a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. The activities made available shall include: (1) Socialization, achieved through activities such as group discussion and conversation, recreation, arts, crafts, music, and care of pets. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interviews conducted and observations made, the licensee did not comply with the section cited above. LPAs interviewed 2 residents who reported a lack of activities occurring regularly within facility. This poses a potential health, safety or personal rights risk to residents in care.
	POC Due Date: 05/02/2024
	Plan of Correction
1 2 3 4	Licensee to submit plan of correction by POC due date of 05/02/2024. Licensee to submit proof of scheduled activities such as a calendar or receipts, or scheduled confirmations for review and approval.

Type B

Section Cited

CCR

87555(a)

87555(a) General Food Service Requirements The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPAs observed an insufficient supply of both fresh fruit and vegetables as well as non-perishable goods, which poses a potential health, safety or personal rights risk to residents in care.
	POC Due Date: 05/02/2024
	Plan of Correction
1 2 3 4	Licensee to submit plan of correction to CCL by POC due date of 05/02/2024. LIcensee to submit proof of sufficient food supply in facility for review and approval.

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: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Julie Florio	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2024

LIC809 (FAS) - (06/04)

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