<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210102881
Report Date: 03/04/2022
Date Signed: 03/04/2022 04:18:53 PM


Document Has Been Signed on 03/04/2022 04:18 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:TINA CAMACLANGFACILITY TYPE:
740
ADDRESS:25 VILLA AVENUETELEPHONE:
(415) 524-8058
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY:12CENSUS: 9DATE:
03/04/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Staff Member #1, Nancy McKee
Administrator, Tina Camaclang		TIME COMPLETED:
04:40 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
Licensing Program Analyst (LPA), Farhaan Sarangi arrived at Schon Hyme Rest Home unannounced for the purpose of conducting a Case Management-Other-Health & Safety (H&S) Inspection. LPA met with Staff Member #1, Nancy McKee. Administrator, Tina Camaclang arrived at 02:24 PM.

Beginning at approximately 01:11 PM, LPA toured the facility with the Staff Member #1 (S1) at which time LPA observed 2 staff members to be working at the facility. 3 out of 3 staff were observed to be properly masked. Staff Member #1 (S1) was reminded that on 03/02/2022 and 03/03/2022 and 03/04/2022 about face masks being used in Residential Care for the Elderly facilities. At 01:11 PM LPA observed that the facility is at a temperature of 72 degrees with exits free from obstruction. LPA observed sufficient perishable and non-perishable foods. LPA observed 4 toilet fixtures and sinks out of 5 had no clogs. The 5th sink in the resident room closest to the kitchen had a clog in the sink. LPA observed water temperature to be at 111 degrees in 5 of 5 residents’ bathrooms and the kitchen at 01:25 PM.

LPA reviewed 2 of 9 resident records at 02:33 PM, including reviewing and ensuring ADLS are being executed. LPA learned that Resident #3 and #4 did not have a reappraisal. Reappraisals were not completed for 2 out of 9 residents, which includes having a reappraisal and having this reappraisal be documented in the Care Plan. (See LIC 9102) LPA learned that 9 of 9 residents did receive showers/baths as identified in their resident care plans.

(Report continued on LIC 809C)
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2022
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 5


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: 03/04/2022
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
26
27
28
29
30
31
32
During the complaint investigation dated for 03/02/2022, LPA learned of additional areas of concern noted during observations of the facility on 03/02/2022 and 03/03/2022. On 03/2/2022 Staff #1 (S1) was observed without a mask and on 03/3/2022 Staff #3 (S#3) was observed with mask down on their neck. Facility staff continues to be non-compliant despite having previously been advised of the PPE requirements during inspections on 06/11/2021, 02/02/2022, 02/24/2022 (See LIC 809D). The facility did not submit an Unusual Incident Report (LIC 624) to Community Care Licensing or notified licensing of the physical plant concerns that were present at the facility. (See LIC 809D) LPA learned on 03/02/2022 that residents were having sponge baths by heating up the water due to not having any warm at the facility (See LIC 809D). On 03/02/2022 and 03/03/2022, LPA observed that the studio room sink was clogged, which is now working properly as of 03/04/2022. However, during an inspection on 03/04/2022, LPA observed the 5th sink in the resident room closest to the kitchen had a clog. (See LIC 809D) Furthermore, the LPA learned that the Administrator did not submit an LIC 624 and did not provide adequate care for the residents in the facility based off of Administrator Qualifications and Duties section 87405(d)(1). (See LIC 809D) During a cursory review of staff records on 03/02/2022, LPA observed that 3 staff members has had no updated training since 2018. Administrator did provide proof of 1st aid for S1, S2 and S3. S1 was the only staff member that had both First Aid and CPR training. LPA observed no proof of CPR for S2 and S3. In addition, it was disclosed by the Administrator to the LPA on 03/03/2022 that she does not have First Aid or CPR. (See LIC 809D)

Non-Compliance Conference has been scheduled for Monday March 07, 2022 at 2 PM to discuss areas of concern and non-compliance. The Licensee and Administrators attendance is required. A letter confirming this meeting was provided during this visit and emailed to the licensee.



The following deficiencies were observed (see LIC 809D) and 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 conducted and appeal of rights provided.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 03/04/2022 04:18 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: 03/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/07/2022
Section Cited

1
2
3
4
5
6
7
87307(d)(3)(b) Personal Accommodations and Services: The following space and safety provisions shall apply to all facilities: All persons shall be protected against hazards within the facility through provision of the following: Information and instruction regarding life protection and other appropriate subjects.
This requirement was not met as evidenced by:
8
9
10
11
12
13
14
Based off of LPA observation on 03/02/2022 S1 was not properly wearing a face covering. On 03/03/2022 LPA observed S3 not wearing a mask properly. Facility was previously advised on 06/11/2021, 02/02/2022 and 02/24/2022 of requirements of facemasks in Residential Care for the Elderly Facilities.
8
9
10
11
12
13
14
Administrator to provide self-certification by 03/07/2022.
Type B
03/07/2022
Section Cited

1
2
3
4
5
6
7
87211(a)(1)(d) Reporting Requirements: Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below.
8
9
10
11
12
13
14
This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. Any incident which threatens the welfare, safety or health of any resident…

This requirement was not met as evidenced by:

Based off of staff interviews and observations, Administrator did not notify the Regional Office of physical plant concerns that were present at the facility since February 15, 2022.
8
9
10
11
12
13
14
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: 03/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 03/04/2022 04:18 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: 03/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/07/2022
Section Cited

1
2
3
4
5
6
7
87405(d)(1) Administrator Qualifications and Duties: The administrator shall have the qualifications specified in
Sections 87405(d)(1). Knowledge of the requirements for providing care and supervision appropriate to the
residents.
This requirement was not met as evidenced by:
8
9
10
11
12
13
14
Based off of staff interviews and observation, Administrator did not provide a comfortable living environment for
residents in care. In addition, Administrator did not submit an incident report nor was any contact made with Santa
Rosa Regional Office regarding the physical plant issues of the facility.
8
9
10
11
12
13
14
Type A
03/07/2022
Section Cited

1
2
3
4
5
6
7
87411(c)(1) Personnel Requirements: All RCFE staff who assist residents with personal activities of daily living shall
receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69.
8
9
10
11
12
13
14
Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American
Red Cross.

This requirement was not met as evidenced by:

Based off of LPA observation of staff records 3 of 4 staff members did not have updated training nor a valid
First Aid and CPR card.
8
9
10
11
12
13
14
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: 03/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 03/04/2022 04:18 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: 03/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/07/2022
Section Cited

1
2
3
4
5
6
7
87303(a) Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement was not met as evidenced by:
8
9
10
11
12
13
14
Based off of LPA observation on March 2, 2022 and March 3, 2022, the studio sink was clogged on both days. In addition, during an inspection on March 4, 2022 at 01:40 PM, LPA observed the 5th sink in the room closest to the kitchen had a clog in the sink.
8
9
10
11
12
13
14
In addition provide proof of how future compliance will be adhered to.
Type A
03/07/2022
Section Cited

1
2
3
4
5
6
7
87468.1(a)(2) Personal Rights of Residents in All Facilities: Residents in all residential care facilities for the elderly shall have all of the following personal rights:

To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
8
9
10
11
12
13
14
This requirement was not met as evidenced by:

Based off of staff interviews, LPA learned that staff was bathing residents by heating up the water and sponge bathing them
8
9
10
11
12
13
14
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: 03/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5