210102881-2-24-2022-21-AS-HDBI-CCD25C-20220309160518

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 210102881
Report Date: 02/24/2022
Date Signed: 02/24/2022 10:47:21 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/23/2021 and conducted by Evaluator Farhaan Sarangi

COMPLAINT CONTROL NUMBER: 21-AS-20211123093809

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: 8	DATE:	02/24/2022
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	House Manager, Nancy McKee		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Staff are mismanaging resident's medications.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Farhaan Sarangi arrived at Schon Hyme Rest Home for the purpose of delivering complaint findings. LPA was met at the door by House Manager, Nancy McKee and was granted access into the facility.

During the course of the investigation, LPA interviewed staff and various outside parties. Various documents were gathered and reviewed including Centralized Stored Medication Record (CSMR), Medication log, Doctors orders and MARS for the resident.

Complaint alleges that Staff are mismanaging resident's medications. Based on interviews with staff and various outside parties and the observation for 8 of 8 residents files, LPA learned that there was an error involving medication administration to R1 which was not administered as prescribed due to medication running out. Responsible Party was notified two days (48 hours) after the medication ran out. However, the facility could not provide proof of the notification to the Responsible Party of the medication running out.(Report continued on LIC 9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 21-AS-20211123093809

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 02/24/2022

NARRATIVE

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In addition, facility provided no evidence of follow-up with the doctor or pharmacy to fill the prescription for R1 prior to the medication running out on October 15, 2021. Subsequently, discontinuation of the prescription was initiated by the doctor on November 19, 2021.

Based upon the statement made by the Administrator and the review of resident records, the preponderance of evidence standard has been met regarding Staff mismanaging resident's medications. Therefore, the above allegation is found to be SUBSTANTIATED. The following deficiency were observed (see LIC 9099D) 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 rights were provided.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 21-AS-20211123093809

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 02/24/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/25/2022 Section Cited CCR 87465(a)(5)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:	1 2 3 4 5 6 7	Administrator agrees to submit facility protocol on when staff are required to ensure that medications are being followed up on and to ensure future compliance. In addition, obtaining and retaining proper discontinuation orders POC due date, 02/25/2022.
	8 9 10 11 12 13 14	(5) The licensee shall assist residents with self-administered medications as needed. This requirement was not met based on record review and interviews indicating that R1 was not administered medication based off of doctors’ orders. This is an immediate risk to health and safety of residents in care.	8 9 10 11 12 13 14	Additionally, Administrator shall submit a training log showing that all staff are following medication orders.
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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: 02/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/23/2021 and conducted by Evaluator Farhaan Sarangi

COMPLAINT CONTROL NUMBER: 21-AS-20211123093809

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: 8	DATE:	02/24/2022
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	House Manager, Nancy McKee		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Facility has inadequate supplies.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Farhaan Sarangi arrived at Schon Hyme Rest Home for the purpose of delivering complaint findings. LPA was met at the door by House Manager, Nancy McKee and was granted access into the facility.

During the course of the investigation, LPA toured the facility on December 3, 2021 and February 2, 2022. LPA found that on December 3, 2021 and February 2, 2022 the facility was clean and at a comfortable temperature with all exits free from obstruction. There was a supply of cleaners, hygiene products and paper products available for residents. In addition, LPA observed hygiene products and paper products available for visitors in both bathrooms that visitors utilize.

Based on the interviews that were conducted and the facility tour conducted, the allegation of Facility having inadequate supplies is Unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 4