198205266-8-28-2023-28-AS-BPEA-CV62L8-20230828172907

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198205266
Report Date: 08/28/2023
Date Signed: 08/28/2023 05:29:53 PM

Document Has Been Signed on 08/28/2023 05:29 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
GREATER LA AC/SC, 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:	08/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Evangeline De Casa - Administrator		TIME COMPLETED:	05:15 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) Bennette Pena conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Eufrosino De Casa/Caregiver and Rodolfo Macalinao/Caregiver and explained the purpose of the visit. Administrator Evangeline De Casa arrived at shortly after and assisted LPA with the inspection. The facility is licensed to serve for 16 ambulatory and 4 non ambulatory residents age 60 and above. There are sixteen (16) residents currently living in the facility. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station and PPE supplies located near the front door. The staff use disposable gloves to clean and disinfect the high touched surfaces in the common areas. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. Facility has some COVID-19 signage posted throughout the facility. Bathrooms have hand washing signs, soap and paper towels. Staff are adhering to infection control requirements. Operational Requirements: A current Plan of Operation was reviewed. The updated Infection Control Plan has been submitted to CCL. Liability Insurance policy is valid and will expire on 01/24/2024. Surety Bond is in effect and in force with bond amount of $5000. Last Fire/Disaster Drill was last conducted on 07/03/2023. Physical Plant/Environment Safety: 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, laundry room, storage room, detached garage and backyard. LPA toured the entire facility and observed all fourteen (14) residents bedrooms and one (1) staff bedroom. LPA observed that the bathroom sinks in bathrooms #2, #4, #6-#10 on address 10337 were clogged and not draining properly. 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. LPA observed a can of bug/insect killer spray under the sink in bathroom #1 which was unlocked and accessible to residents. Administrator took the bug spray immediately and kept it in a locked cabinet. All showers in bathrooms accommodate non-ambulatory clients. The hot water tested between 109.5F - 115.8F 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. However, LPA observed that the facility did not have an operational signal system in the resident rooms (bedrooms #8-#10 and bedrooms #11-#14) with exit doors leading to the side yard and backyard. All sharps were observed to be stored in a kitchen cabinet, which has a locked door to the entrance. Backyard was inspected and has a shaded area and sitting area. LPA observed clutter and miscellaneous unused items in the side yard and backyard.There were seven (7) fire extinguishers observed in the facility mounted on the walls in several areas of the buildings. Fire extinguishers were last inspected on 01/25/2023. Smoke alarms and carbon monoxide were tested and operable. There are no firearms or weapons stored at the facility. Additionally, sufficient PPE supplies were observed stored in the garage and readily available in common areas for the residents to use. ***REPORT CONTINUED ON LIC809-C***

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CAMELOT RESIDENTIAL HOME	FACILITY NUMBER: 198205266
	VISIT DATE: 08/28/2023

NARRATIVE

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Staffing: A total of twelve (12) staff members including the Administrator provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility.
Personnel Records-Training: LPA reviewed four (4) staff files and confirmed health screenings and fingerprint clearances. Proof of staff training, health clearance, vaccinations and 1st Aid/CPR training are current. Administrator certificate is valid and expiring on 11/08/2024. Administrator has a valid HIV/AIDS training proof at the time of visit.
Resident Records-Incident Reports: LPA reviewed resident files for R1-R5. Resident files are maintained at the facility. Physician's Report (including TB and Ambulatory Status), Consent For Medical Treatment, Client Cash Resources, Appraisal and Needs Service Plan, Special Incident Reports, Resident Personal Property and Resident Personal Rights observed.
Resident Rights-Information: Resident personal rights are posted. Per Administrator, facility provides internet services to all residents and have access to the facility phone.
Planned Activities: Planned activities are made available to residents. Facility provides equipment and space to accommodate both outdoor and indoor activities. Weekly activities had been developed.
Food Service: There are sufficient food supplies of 2-day perishable and 7-day non-perishable items. The food is properly stored in the refrigerator (clean and well maintained). There are three (3) residents with special diet/diabetic diet residing at this facility. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.
Incidental Medical Services: Medication was observed to be centrally stored in a separate room in address 10337 and all cleaning supplies/toxins were stored in a locked storage room next to the detached garage.
LPA reviewed 4 resident files to confirm emergency contacts are updated. Medications were reviewed for R1-R5 to confirm medication is given as prescribed and is documented properly. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. Medications are bubbled packed.
Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan.
Residents with SHN: Not-Applicable.

Deficiencies cited on LIC 809D. Exit interview, appeals rights and a copy of this report was provided to the Administrator, Evangeline De Casa.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/28/2023 05:29 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
GREATER LA AC/SC, 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: 08/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, the Administrator did not comply with the section cited above in that LPA observed a can of bug/insect killer spray under the sink in bathroom #1 which was unlocked and accessible to residents which poses an immediate health, safety or personal rights risk to residents in care.
	POC Due Date: 08/28/2023
	Plan of Correction
1 2 3 4	Administrator took the spray can of insect killer and kept it in a locked cabinet immediately. *Cleared during the visit.*

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: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 08/28/2023 05:29 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
GREATER LA AC/SC, 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: 08/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(e)(6)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, the Administrator did not comply with the section cited above in which LPA observed that the bathroom sinks in bathrooms #2, #4, #6-#10 were clogged and not draining properly which poses/posed a potential health, safety or personal rights risk to residents in care.
	POC Due Date: 09/11/2023
	Plan of Correction
1 2 3 4	Administrator will contact a plumber to inspect and repair the clogged drainage in the residents bathroom sinks and submit a copy of the service report/receipts to CCL/LPA by POC due date.

Type B

Section Cited

CCR

87303(i)(1)(A)

Maintenance and Operation

(i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (A) Operate from each resident's living unit. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, the Administrator did not comply with the section cited above in that LPA observed that the facility did not have an operational signal system in the resident rooms with exit doors leading to the side yard and backyard which poses/posed a potential health, safety or personal rights risk to residents in care.
	POC Due Date: 09/11/2023
	Plan of Correction
1 2 3 4	Administrator will ensure that the facility has a functional signal system installed in each resident's living unit and submit proof of correction such as photos and equipment receipts to CCL/LPA by POC due date.

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: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 08/28/2023 05:29 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
GREATER LA AC/SC, 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: 08/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307(d)(6)

Personal Accommodations and Services

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, the Administrator did not comply with the section cited above in that LPA observed clutter and miscellaneous unused items in the side yard and backyard which poses/posed a potential health, safety or personal rights risk to residents in care.
	POC Due Date: 09/11/2023
	Plan of Correction
1 2 3 4	Administrator will remove and dispose the unused items and clear the clutter in the side yards and backyard. Administrator will send proof of correction such as photos to CCL/LPA by POC due date.

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: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023

LIC809 (FAS) - (06/04)

Page: 5 of 5