210102881-3-11-2022-21-AS-CFGS-CCEUG3-20220311143340

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 210102881
Report Date: 03/11/2022
Date Signed: 03/11/2022 02:34:02 PM

Document Has Been Signed on 03/11/2022 02:34 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 HOME		FACILITY NUMBER:	210102881
ADMINISTRATOR:	TINA CAMACLANG		FACILITY TYPE:	740
ADDRESS:	25 VILLA AVENUE		TELEPHONE:	(415) 524-8058
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94901
CAPACITY:	12	CENSUS: 0	DATE:	03/11/2022
TYPE OF VISIT:	Office	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Andrew T. So - Licensee		TIME COMPLETED:	02:33 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	Regional Manager Carla Nuti-Martinez, Licensing Program Manager Hope DeBenedetti, Licensing Program Analyst Carla Fernandes-Goes, and Andrew T. So - Licensee met with the purpose of holding a Non-Compliance Conference. Licensee Andrew T. So was asked to be in attendance (he and his spouse Pak-Lin are the licensees on record). This is a Non-Compliance conference regarding the operation of Schon Hyme Rest Home. During the meeting the following items were discussed: · Facility was without heat and hot water for approximately two weeks · Masking Requirements · Staff Training Records · Medication Management · Background Clearances · Administrator Qualifications and Duties · Staff training Licensee agrees to provide the following Items by March 15, 2022: · Pacific Gas & Electric receipts for repairs · Updated LIC 500 - Lease Agreement - Water Log - Room temperature log - Albertina Camaclang's current Administrator Certificate Continued LIC 809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022

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

FACILITY NAME: SCHON HYME REST HOME	FACILITY NUMBER: 210102881
	VISIT DATE: 03/11/2022

NARRATIVE

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- LIC 308
- LIC 610
- Room temperature log
- LIC 610 Emergency Disaster Plan
- LIC 610 E-S Supplemental Emergency Disaster Plan for RCFE
- LIC 9020 Register of facility Client's/Resident's

Administrator documents will be submitted by March 14, 2022
LIC 200 Application Information (original)
LIC 308 Designation of Facility responsibility (designation of who is the administrator)
Administrator Certificate
First Aid Certificate
Administrator Resume (in small facilities if possible)
LIC 500 Personnel Report
LIC 501 Personnel Record
LIC 503 Health Screening Report - personnel (keep on facility staff file to be reviewed)
TB test that shows "negative" (keep on facility staff file to be reviewed)
LIC 508 Criminal Record Statement
LIC 9182 Criminal Record Exemption Transfer Request
Copy of Personal ID

There were no deficiencies cited at this time.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022

LIC809 (FAS) - (06/04)

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