198205266-5-15-2026-28-AS-DSIS-DUAPCY-20260521111241

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198205266
Report Date: 05/15/2026
Date Signed: 05/15/2026 12:33:16 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/12/2026 and conducted by Evaluator Tena Herrera

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20260512160512

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:	05/15/2026
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Evangeline De Casa - Administrator		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Staff did not ensure that the resident's room was maintained in a clean and sanitary condition.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint visit to investigate the allegation listed above. LPA met with Administrator Evangelina and explained the purpose of the visit.

The investigation consisted of the following:

LPA obtained copies of the Staff and Resident rosters, toured facility, and conducted interviews with 2 Staff and 5 Residents.

(Continued on LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20260512160512

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/15/2026

NARRATIVE

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The investigation revealed the following:

Allegation: Staff did not ensure that the resident's room was maintained in a clean and sanitary condition.

It is alleged that staff leave residents floor and toilet unclean. LPA toured facility, restrooms and flooring in both main unit with kitchen and neighboring unit did appear to have unclean floors, restrooms in both units were entered and appeared clean and sanitary. LPA toured 4 individual rooms outside of units, each room has a private bath, floors and restroom in each room appeared clean and sanitary. LPA interviewed 2 staff and each denied the allegation and stated that the facility is swept and mopped daily, rooms are cleaned regularly or as needed when a resident mentions cleaning is needed. LPA interviewed 5 Residents and 4 denied the allegation; they stated staff clean regularly and have not observed the floors or restroom being left dirty or unsanitary and don’t find this as a concern.

Based on statements and interviews conducted with staff/residents, and LPA’s observations, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2026

LIC9099 (FAS) - (06/04)

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