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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198205266
Report Date: 08/13/2021
Date Signed: 08/19/2021 10:07:39 AM

COMPREHENSIVE INSPECTION
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CAMELOT RESIDENTIAL HOMEFACILITY NUMBER:
198205266
ADMINISTRATOR:JEFFERSON BAUTISTAFACILITY TYPE:
740
ADDRESS:10337 BEACH STREETTELEPHONE:
(562) 866-3955
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY:20CENSUS: 15DATE:
08/13/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Evangeline De CasaTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Christine Wong conducted an annual required visit. LPA met with the stafffrom Kitchen- Eufrosino De Casa and explained the reason for the visit. Shortly after, the administrator
Evangeline De Casa arrived and assisted with the visit LPA used the infection control tool to evaluate the
facility. LPA observed the facility plant, COVID-19 procedures, reviewed residents' medications, observed
food supply, and reviewed resident and staff files. Facility has submitted a mitigation plan and approved on
7/26/2021.

The facility consists of (10) resident bedrooms and (8) bathrooms on address 10337 and (4) residents
bedrooms and (2) bathrooms on address 10329 (2) , dining area, living room/TV area , outdoor activity areas,smoking area and garage w/ laundry area. LPA toured the entire facility and observed 6 out of the 14
bedrooms including room#3, #4, #5, #6, #7 and #8. All bathrooms were clean with required grab bar and nonskid mats in place. LPA observed bathroom#4, #5, #6 on address 10037 and bathroom#1 on address 10329,some of the light bulbs are missing and the overhead lighting was missing too. In addition, LPA also observed flies were flying around in all bathrooms. Hot water was tested and noted between 115.5 and 117.8 degrees.All rooms checked mattresses and bedsprings are in good repair, adequate lighting and closet space observed. LPA also observed perishable and non-perishables food supply was adequate at time of visit. Outside grounds were toured. Backyard was free of debris, exit ways and pathways were clear of hazards.

LPA's reviewed 5 resident files to confirm emergency contact is updated. LPA also reviewed 3 staff files to
confirm health screenings and fingerprint clearances. LPA's reviewed 5 residents' medications. Resident #1(R1's) Acetminophen 500mg and Resident #2 (R2's) Benztropine Mesylate 1mg and Metformin HCL and
Resident#3 (R3) Gabapentin 300mg and Resident#5 (R5's) Olanzapine 20mg were not present at the facility. Administrator indicated the medications had run out and hasn't delivered yet
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CAMELOT RESIDENTIAL HOME
FACILITY NUMBER: 198205266
VISIT DATE: 08/13/2021
NARRATIVE
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The deficiencies cited are documented on the attached 809D. A copy of the report and appeal rights will be
provided to administrator Evangeline De Casa.

Due to some technical difficulties and LPA was not able to print the documents during the required inspection and LPA emailed the documents to administrator Evangeline De Casa.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CAMELOT RESIDENTIAL HOME
FACILITY NUMBER: 198205266
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/27/2021
Section Cited

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87303(a) Maintenance and Operation
The requirmeent is not met as evidenced by :Based on LPA's observation, LPA obsered bathroom#4, #5 and #6 on address 10037 and bathroom #1 on adderss 10329,the bathroom light buld were out and Room#5 and #6, the overhead lighting were out too and LPA also observed all
bathroom have flies were flying around which poses/posed a potential health, safety or personal rights risk to persons in care
Type B
08/14/2021
Section Cited

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87465(c)(2) Incidental Medical and Dental Care. The requirement is not met as evidenced by: Based on resident record, LPA observed Resident #1 (R1's) Acetminophen 500mg and Resident #2 (R2's) Benztropine Mesylate 1mg and Metformin HCL and Resident#3 (R3) Gabapentin 300mg and Resident#5 (R5's) Olanzapine 20mg were
not present at the facility which poses/posed a immediatel health, safety or personal rights risk to persons in care.

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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: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:
DATE: 08/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2021
LIC809 (FAS) - (06/04)
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