198205266-7-18-2024-28-AS-THEA-D7AR6L-20240718124455

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198205266
Report Date: 07/18/2024
Date Signed: 07/18/2024 12:45:02 PM

Document Has Been Signed on 07/18/2024 12:45 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:	07/18/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Rodolfo Macalinao - Caregiver		TIME COMPLETED:	01:00 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) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and was greeted by Rudolfo Macaliano (Caregiver) who allowed entrance to the facility, shortly after Evangeline De Casa (Administrator) arrived to assist with the visit, the purpose for today’s visit was explained. The facility is licensed to serve 16 ambulatory and 4 non-ambulatory residents ages 60 and above. There is an approved hospice waiver for 1 resident. The facility currently has 16 residents. - The facility is a single-story home located in Bellflower, Ca. A tour of the facility consists of 2 separate units and independent rooms with private bath along the back/outside. Main unit consists of kitchen, living room, dining areas, 4 resident bedrooms, 1 staff room/storage/medication room, 1 staff office. Leading to the exterior there are 6 private units with private baths. Detached garage and storage rooms/staff break room/backup refrigerator and freezer with food. Separate unit consists of 4 bedrooms and 2 bathrooms. There is a locked laundry area and linen storage near the separate unit. Facility has a large outside activity area, back yard, front yard and parking area in back yard. There is a fire sprinkler system throughout the facility. - LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit todays visit and the initial visit and observed the following: Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting residents’ medications. Staff are cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan maintained at the facility. Operational Requirements: The facility has an approved fire clearance, there is a plan of operation with required Infection Control Plan and facility maintains liability insurance, however, the amount covered on aggregate was not the amount that facility is required to maintain (citation issued and will be documented on 809D). Fire Marshal arrived during visit and conducted an annual inspection with no issues. Physical Plant & Environment Safety: LPA toured facility, residents’ bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. The front yard is free of debris/hazards and the outdoor and passageways are free of obstruction. (Continued on LIC809-C)

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024

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

FACILITY NAME: CAMELOT RESIDENTIAL HOME	FACILITY NUMBER: 198205266
	VISIT DATE: 07/18/2024

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
26
27
28
29
30
31
32

(Continued) No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. The hot water temperature was tested throughout the facility and measured within the required range of 105-120 degrees F. All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept in a locked and are inaccessible to residents. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged. Last fire/disaster/earthquake drill was conducted on 7/3/24. Staffing: There appears to be sufficient staffing at all times in the facility. With night staff that is trained and able to assist in care and supervision of the residents in the case of an emergency. Personnel Records-Training: Staff has criminal record clearance, current First-Aid/CPR/AED training along with training in postural supports, medication assistance, and other ongoing training are documented in personnel files. LPA reviewed 4 staff files, Staff #3 and Staff #2 were missing training in Alzheimer’s and Dementia (citation will be issued and documented on 809D). Administrator Evangeline De Casa maintains a valid administrator certificate that expires on 11/8/2024. Resident Records-Incident Reports: Resident files are kept in a secure location (within staff office) and have the following documents in their files - Pre-admission appraisal/Appraisal Needs & Services Plan, Admission Agreements, Identification & Emergency Information and current Physician's Report. LPA reviewed 4 Resident Files with no issues observed. Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility has the following posters posted: Residents Rights, Complaint Poster, and Ombudsman. Planned Activities: Facility provides scheduled activities and have a variety of activities to choose from within the facility. There is an outdoor activity area available for the residents. Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. Incidental Medical & Dental: Medication is properly labeled and are centrally stored in locked staff room and locked cabinet, medication was observed to be in their original containers. Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Residents with Special Health Needs: There are no bedridden or residents with postural supports at this facility.
- Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit will be documented on the LIC809-D.
- Exit interview held, a copy of the report, appeal rights and list of confidential names to identify staff, were provided to Evangeline De Casa.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 07/18/2024 12:45 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: 07/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.605

Other Provisions

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as the current liability insurance coverage was observed to be for $1,000,000 (liability) and $2,000,000 (aggregate), which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/01/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator to update thier liability insurance coverage to the required amounts mentioned above (at least one $1,000,000 per occurrence and $3,000,000 in the total annual aggregate) and send the updated insurance information to LPA by POC due date via email (tena.herrera@dss.ca.gov).

Type B

Section Cited

HSC

1569.625(c)(8)

Other Provisions

(c) The training shall include, but not be limited to, all of the following: (8) The special needs of persons with Alzheimer’s disease and dementia, including nonpharmacologic, person-centered approaches to dementia care. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as LPA observed that Staff #2 and Staff #3 were missing required Alzheimer’s disease and dementia training within their personnel files, LPA asked administrator if there was anywhere else this training would be documented in which they replied no, this poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/01/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator to ensure all staff have proper Alzheimer’s disease and dementia training within their personnel files, and send proof of trainings from Staff #2 and Staff #3 to LPA via email by POC due date (tena.herrera@dss.ca.gov).

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: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3