216804291-4-9-2025-21-AS-CFES-DFKQNG-20250409121907

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216804291
Report Date: 04/09/2025
Date Signed: 04/09/2025 12:19:15 PM

Document Has Been Signed on 04/09/2025 12:19 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	VILLA GARDENS		FACILITY NUMBER:	216804291
ADMINISTRATOR/ DIRECTOR:	CAMACLANG, ALBERTINA		FACILITY TYPE:	740
ADDRESS:	25 VILLA AVENUE		TELEPHONE:	(650) 722-3521
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94901
CAPACITY: 12		CENSUS: 4	DATE:	04/09/2025
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:15 AM
MET WITH:	Staff Member, Nancy Mckee, and Applicant, Tina Camaclang		TIME VISIT/ INSPECTION COMPLETED:	12:25 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	At approximately 9:15AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Pre-Licensing visit and met with Staff Member, Nancy McKee. Applicant, Tina Camaclang, arrived during visit at approximately 10AM. Applicant has applied for a Change of Ownership for an existing Residential Facility for the Elderly (RCFE) identified as Schon Hyme Rest Home (210102881). Facility currently provides care to older adults and has a dementia care program on file. Facility received an approved fire clearance dated 02/13/2025 that allows for a total capacity of 12 non-ambulatory residents. Upon arrival, LPA was informed that there are currently 4 residents in care. LPA conducted a physical plant walk-through. LPA observed the following: Per facility sketch, facility is a one story residence with 8 resident bedrooms, 5 1/2 bathrooms, 1 staff break room, and common areas. Facility has a separate building on-site for laundry. Facility was found to be clean with all exits free from obstruction. Facility had emergency lighting. Facility's door alarms were tested and operational. LPA observed required postings including the CCL Complaint Poster and Personal Rights. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Facility's hot water temperatures for all sinks were within Title 22 Regulations of 105F to 120F. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Toxins were observed to be stored inaccessible to residents. Bathrooms were equipped with necessary grab bars and non-slip floors/mats were present. All resident rooms were furnished with a bed, lamp, dresser, and chair. Facility has sufficient items for cooking and eating. Facility has indoor/outdoor areas for visiting and activities. Facility's fire extinguishers were newly purchased and were observed to be fully charged. Facility's smoke and carbon monoxide detectors were tested and operational. LPA confirmed that contents of the facility's First Aid Kit were sufficient. Continued on LIC809C

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Caitlynn Felias
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: VILLA GARDENS	FACILITY NUMBER: 216804291
	VISIT DATE: 04/09/2025

NARRATIVE

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Continued from LIC809

LPA and Applicant discussed the following items:

Hospice Waiver - Applicant to apply for a waiver if it's decided they want hospice care in the facility
Updated Admission Agreements and Care Plans - Applicant understands that they will need to complete new Agreements and Care Plans for all residents once Facility License is approved.
Complaint Poster (PUB 475) - Applicant to ensure required poster is correct size (20x26).
Protective Mattress Pads - Applicant understands that mattress pads should be available on-site for resident use if requested
Guardian background clearances and associations - Applicant understands that all current staff members associated to Schon Hyme Rest Home (210102881) will need to be transferred and associated to new facility license once approved.

Applicant to submit proof of protective mattress pads and correctly sized Complaint Poster. Proof to be submitted to Community Care Licensing (CCL) by 04/18/2025. Component III was reviewed with Applicant.

No Deficiencies or Advisories given during visit. Pre-Licensing completed. Facility is ready to be Licensed as an Residential Facility for the Elderly (RCFE).

LPA will submit Pre-Licensing Application Report to the Application Unit Analyst in Sacramento. Application Unit Analyst will notify Applicant of Status.

Exit interview conducted. Copy of report discussed and provided. Signature on form confirms receipt of documents.

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Caitlynn Felias
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025

LIC809 (FAS) - (06/04)

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