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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210102881
Report Date: 03/16/2022
Date Signed: 03/16/2022 10:15:46 AM


Document Has Been Signed on 03/16/2022 10:15 AM - 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: 8DATE:
03/16/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Staff Member #1, Nancy McKeeTIME COMPLETED:
10:30 AM
NARRATIVE
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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. Licensee, Andrew So arrived at 09:45 AM.

LPA toured the facility at 09:14 AM and found 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 5 toilet fixtures and sinks out of 5 had no clogs. In addition, LPA checked water temperatures in 5 out of 5 faucets and found that the temperature of the water was at 112 degrees. During the Case Management-Other-Health & Safety (H&S) inspection, LPA learned that the facility still does not have an active Administrator for the facility as previously cited during an office visit on March 7, 2022. (See LIC 809D)

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Civil Penalty assessed during this inspection. 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: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2022
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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Document Has Been Signed on 03/16/2022 10:15 AM - 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: 03/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/18/2022
Section Cited

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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:
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Based on LPA observation and interview, there is still no active administrator for the facility. Civil Penalty assessed for Failure to Correct previously cited deficiency and repeated violation(s).
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Licensee to submit association request for a qualified Administrator and submit proof of new Administrator by March 18, 2022.

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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 DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2022
LIC809 (FAS) - (06/04)
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