210102881-3-7-2022-21-AS-FSAI-CCB26L-20220307160719

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 210102881
Report Date: 03/07/2022
Date Signed: 03/07/2022 04:08:00 PM

Document Has Been Signed on 03/07/2022 04:08 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:	DATE:	03/07/2022
TYPE OF VISIT:	Office	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Albertina Camaclang		TIME COMPLETED:	04:15 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, Farhaan Sarangi and Albertina Camaclang 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). For personal reasons Mr. So was not able to be in attendance. The Non-Compliance Conference is being postponed until licensee can be present, however, CCL staff and administrator held an office meeting to discuss areas of concern identified by CCL 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: · Death Certificate of Licensee · Pacific Gas & Electric receipts for repairs · Updated LIC 500 - Lease Agreement - Water Log - Room temperature log - Albertina Camaclang's current Administrator Certificate (Report continued on LIC 809C)

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2022

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: 03/07/2022

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
- Copy of Certificate of Liability Insurance

CCL will schedule a Non-Compliance meeting with the License and determine if they are willing to proceed. Caregiver & Medication training Administrator Certificate Requirements were given to the Administrator.

CCL is requesting verification of Administrator Certificate Renewal by tomorrow, March 8, 2022. Licensee agrees to designate another interim Administrator with an active certificate should Administrator not be able to provide verification.

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 DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/07/2022 04:08 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: 03/07/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/08/2022 Section Cited	1 2 3 4 5 6 7	87405 Administrator - Qualifications and Duties -(a) All facilities shall have a qualified and currently certified administrator.This requirement has not been met as evidenced by:
	8 9 10 11 12 13 14	Based on LPA interview, Designee indicated Administrator certificate had expired and is in the process of submitting training certification necessary for renewal. This is an immediate risk to the Health and Safety of Residents in Care.	8 9 10 11 12 13 14	Administrator's Certificate renewal by POC due date March 8, 2022. Licensee agrees to ensure the designated Administrator assigned is present at the facility sufficient number of hours per regulation and is identified on the LIC 500.
	1 2 3 4 5 6 7
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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: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2022

LIC809 (FAS) - (06/04)

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