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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210102881
Report Date: 04/05/2022
Date Signed: 04/05/2022 11:30:54 AM


Document Has Been Signed on 04/05/2022 11:30 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:MENDOZA, CECILEFACILITY TYPE:
740
ADDRESS:25 VILLA AVENUETELEPHONE:
(415) 524-8058
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY:12CENSUS: 8DATE:
04/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Care Giver, Nancy Deleon
Facility Staff Member, Tina Camaclang		TIME COMPLETED:
11:45 AM
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License Program Analyst (LPA) Farhaan Sarangi arrived unannounced to conduct an Required – 1 year inspection of the facility. Facility is also on a Non-Compliance Plan. LPA met with Care Giver, Nancy Deleon, and was granted access into the facility. Facility staff member, Tina Camaclang arrived 45 minutes later.

LPA toured the facility with Care Giver, Nancy Deleon. During the tour, LPA observed the facility to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on November 2021 at the time of the inspection. First Aid kit was found to be appropriate during the inspection. There are emergency lights in many of the fixtures in the common areas of the facility that come on should a power outage occurs. Facility smoke detectors and carbon monoxide detectors were observed and tested during this inspection. Auditory alerts were equipped on the exit door and the balcony door leading to the backyard. Hot water temperature measured within Title 22 acceptable regulation of 105 to 120 degrees in resident’s bathrooms while touring facility. Facility serves residents with dementia and has special care plan of operation and programming. There was a sufficient supply of perishable and non-perishable foods. Medications were centrally stored in a locked medication cabinet between the kitchen and resident’s bedroom in the facility. There was a supply of cleaners, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. A tour of all resident’s bedrooms were conducted, and bedrooms inspected have lighting & appropriate furnishing. Beds are outfitted with Mattress pads as per Title 22 regulations.

LPAs advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Disaster Drills were conducted December 2021. PPE was inspected and found to be insufficient at this time (See LIC 9102). PPE training was also conducted. N95 Fit testing will be scheduled (See LIC 9102). No deficiencies observed or cited during today's Required 1 year inspection. Exit interview was conducted and a copy of this report was emailed to the facility email address on file.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2022
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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