210102881-3-4-2022-21-AS-BMOS-CCJSPT-20220315140340

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 210102881
Report Date: 03/03/2022
Date Signed: 03/04/2022 08:24:06 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
03/02/2022 and conducted by Evaluator Carla Fernandes-Goes

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20220302141431

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: 9	DATE:	03/03/2022
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Tina Camaclang - Administrator		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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There is no heat at the facility.

There is no hot water.

INVESTIGATION FINDINGS:

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The Department conducted a complaint investigation regarding the allegations listed above. Licensing Program Analyst Fernandes-Goes arrived announced for the purpose of closing the investigation and met with administrator Tina Camaclang.

On 3/2/2022 at 3:50 PM, LPA Fernandes-Goes toured the facility; conducted interviews; acquired documentation; and made observations of the facility. During tour of the facility with staff Nancy, interviews with 2 out of 9 residents, staff S1, and administrator on 3/2/2022, LPA learned that facility has had no heat or hot water since 2/15/2022 when there was a smell of gas in the facility and PG&E was contacted. LPA observed facility has 4 space heaters and only 1 in a resident room was on during 3/2/2022 visit. Per staff and administrator when space heater in the living is turned on and/or all 3 heaters in resident’s rooms, “It triggers power to go off. It is an old house.”.

Substantiated

Estimated Days of Completion:

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

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022

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

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20220302141431

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: 03/03/2022

NARRATIVE

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In addition, residents have not had showers and facility is only able to give sponge baths by heating water. LPA measured hot water temperature on residents faucets and 3 out of 3 residents' bathroom faucets measure between 60.2 degrees F and 60.4 degrees F falling out of required Title 22 Regulation of 105 to 120 degrees F. Facility heat was not working and off, facility was at a cold temperature with residents in sweaters, blankets, and some with a knit cap. (see picts) When this incident occurred, Department was never contacted by facility regarding this issue. Administrator stated that plumbers started working on this issue on 2/16/2022 and that 3/2/2022 they finished the job and facility was waiting for plumber to contact PG&E to turn power back on. During today's visit on 3/3/2022, Administrator Tina stated that the gas situation actually started on 2/23/2022 and plumbers started working on 2/24/2022. Facility administrator was able to get PG&E to do an emergency ticket, and heat & hot water is back on today 3/3/2022. Based on observations and interviews facility had no heat or hot water from 2/23/2022 until 3/2/2022. (see confidential name list, LIC 809-D)

According with complaint allegation "There is no heat at the facility.”, and “There is no hot water.” there were related observations made during visit. Based on LPAs' observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

In addition, meeting 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.

Appeal of Rights Given.

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

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 21-AS-20220302141431

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: 03/03/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/04/2022 Section Cited CCR 87303(e)(2)	1 2 3 4 5 6 7	Water supplies&plumbing fixtures shall be maintained as follows: temp of hot water used by residents to attain a temperature of not less than 105 degree F & not more than 120 degree F .	1 2 3 4 5 6 7	Facility to ensure that hot water temperature stays within Title 22 Regulations of not less than 105 degree F and not more than 120 degree F. Facility to adjuste hot water temperature and submit a
	8 9 10 11 12 13 14	This requirement is not met as evidenced by:Based on obs and interviews licensee didn't comply w/section cited above in 3 of 3 faucets since 2/15/22 which poses/posed immediately health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14	7 day log by POC due date of 3/11/2022 in order to clear this citation. Note: during today's visit administrator adjusted the water.
Type A 03/03/2022 Section Cited CCR 87303(b)(1)	1 2 3 4 5 6 7	Maintanance & Operation: The facility shall heat rooms that residents occupy to a minimum of 68 degree F. This requirement is not met as evidenced by: Based on obs and interviews	1 2 3 4 5 6 7	Facility to maintain heat on rooms that residents occupy to a minimum of 68 degree F and shall cool rooms to a comfortable range, between 78 degrees F and 85 degrees F. Administrator to provide Department
	8 9 10 11 12 13 14	licensee didn't comply w/section cited above in 9 of 9 resident's bedrooms, living room,dinning room since 2/15/22 which poses/posed immediately health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14	today 3/3/2022 with proof that heater is working from repair company in order to clear this citation.

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

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 21-AS-20220302141431

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: 03/03/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/04/2022 Section Cited CCR 87468(a)(2)	1 2 3 4 5 6 7	Personal Rights:Residents in all residential care facilities for the elderly ...:To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.This requirement isn't met as evidenced by:	1 2 3 4 5 6 7	Facility administrator and licensee agrees to submit an LIC 9098 self-certification to certify that all residents will have a safe, healthful and comfortable accommodations, furnishings and equipment at all
	8 9 10 11 12 13 14	Based on obs and interviews licensee didn't comply w/section cited above in 9 of 9 residents living at facility since 2/15/22 which poses/posed immediately health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14	times; and that they have read Title 22 Regs # 87468 and understand facilities responsibilities. LIC 9098 self-certification to be submitted to Department by POC date of 3/4/2022.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 4