198205266-8-29-2022-28-AS-VMAO-CHRTXT-20220829150741

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198205266
Report Date: 08/29/2022
Date Signed: 08/29/2022 03:07:52 PM

Document Has Been Signed on 08/29/2022 03:07 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	CAMELOT RESIDENTIAL HOME		FACILITY NUMBER:	198205266
ADMINISTRATOR:	JEFFERSON BAUTISTA		FACILITY TYPE:	740
ADDRESS:	10337 BEACH STREET		TELEPHONE:	(562) 866-3955
CITY:	BELLFLOWER	STATE: CA	ZIP CODE:	90706
CAPACITY:	20	CENSUS: 16	DATE:	08/29/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Evangeline De Casa- Administrator		TIME COMPLETED:	03:15 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	Licensing Program Analyst (LPA) V. Maldonado conducted an annual required inspection at the facility. LPA Maldonado met with staff Eufrosino De Casa (cook) 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. During today's visit, LPA observed the facility plant, COVID-19 procedures, reviewed residents' medications, observed food supply, and reviewed resident and staff files. The 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 areas, living room/TV area , outdoor activity areas, smoking area and garage w/ laundry area. LPA toured the entire facility and observed 8 out of the 14 bedrooms including rooms# 5, #7-#12, and #14. LPA observed bathroom # 1, #2, and #5 on address 10037 and bathroom#1 on address 10329. All bathrooms toured were observed to be clean, fully stocked with hand soap, and paper towels, and had the required grab bars and nonskid mats in place. All showers in bathrooms accommodate non-ambulatory clients. The hot water tested between 114.8F - 119.2F in all bathrooms. All rooms toured were observed to have the required linens and furniture were in good repair. Adequate lighting and closet space was observed in all rooms. LPA also observed adequate perishable, non-perishable, and emergency food supply at time of the visit. All sharps were observed to be stored in a kitchen cabinet, which has a locked door to the entrance. Outside grounds were toured. Backyard was free of debris, exit ways and pathways were clear of hazards. Several fire extinguishers near entrances/exits and in the hallways were observed to be fully charged and have recent inspections. The smoke and carbon monoxide detectors were tested and observed to be functioning, during today's visit. Additionally, sufficient PPE supplies were observed stored in the garage and readily available in common areas for the residents to use. Medication was observed to be centrally stored in a separate room in address 10337 and all cleaning supplies/toxins were stored in a cabinet in the hallway. (Report continued on LIC809-C...)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2022

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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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: 08/29/2022

NARRATIVE

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LPA reviewed 4 resident files to confirm emergency contacts are updated. LPA also reviewed 3 staff files to
confirm health screenings and fingerprint clearances. LPA reviewed 4 residents' medications.

At 11:25 a.m., LPA Maldonado observed one of the resident's medication box on top of the counter in the dining room- easily accessible to other residents in care. When staff was asked about it, it was stated that the resident had just received their medication and immediately took the medication to store it away.

Deficiencies were observed during today's visit and will be cited per Title 22, Division 6, Chapter 8. Refer to the LIC809-D page for the deficiencies cited.

An exit interview was conducted with administrator Evangeline De Casa and a copy of this report and appeal rights were provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/29/2022 03:07 PM - 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, 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: 08/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(2)

(h) The following requirements shall apply to medications which are centrally stored: 2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations and interviews, the licensee did not comply with the section cited above by failing to ensure resident medications are locked and inaccessible to persons in care, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/30/2022
	Plan of Correction
1 2 3 4	Licensee will complete in-service training with all staff who provide direct care to residents and provide a copy of the training material and sign in sheet for the training completed by the POC due date of: 08/30/22.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2022

LIC809 (FAS) - (06/04)

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