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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198205266
Report Date: 07/16/2026
Date Signed: 07/16/2026 03:39:16 PM

Document Has Been Signed on 07/16/2026 03:39 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 HOMEFACILITY NUMBER:
198205266
ADMINISTRATOR/
DIRECTOR:		JEFFERSON BAUTISTAFACILITY TYPE:
740
ADDRESS:10337 BEACH STREETTELEPHONE:
(562) 866-3955
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY: 20CENSUS: 13DATE:
07/16/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:56 AM
MET WITH:Evangeline De Casa - AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:50 PM
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Licensing Program Analysts (LPA) Tena Herrera conducted the required annual inspection. LPA met with Evangeline De Casa (Administrator) and explained the purpose for today’s visit. 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.

- This is single-story facility 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 used the Compliance and Regulatory Enforcement (CARE) tools for the visit todays visit and observed the following:


Infection Control: The facility maintains the required Infection Control Plan.
Operational Requirements: The facility has an approved fire clearance and maintains valid liability insurance
Planned Activities: There is an outdoor activity area available for the residents. Administrator Stated that Staff #5 is the designated staff with the primary responsibility being to plan,prepare and conduct activities, however, after file review S5 does not have the proper training or education. LPA arrived to facility at 10:56am and left at 3:20pm, there were no observations of activities being conducted and S5 was not present at facility, citation being issued and detailed on LIC809-D page.
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.
(Continued on LIC809-C)
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/16/2026
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 6
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 07/16/2026
NARRATIVE
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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. 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 areas with a lock, however, during tour LPA observed unlocked cleaning supplies/chemicals in main bulidings bathroom and in Resident #2's bathroom within Room #1, citation will be issued. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged.
Staffing & Personnel Records-Training: There appears to be sufficient staffing at all times in the facility. 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 5 staff files with no issues. Administrator Evangeline De Casa maintains a valid administrator certificate that expires on 11/8/2026.
Resident Records-Incident Reports: Resident files are kept in a secure location 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 5 Resident Files with no issues.
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.
Incidental Medical & Dental: LPA conducted medication review and observed the following errors: R7 is missing 1 PRN medication; Facility does not have any the required documentation of medication review from nurse/pharmacist; R6 and R7 have 1 medication that is not properly labeled; Facility is prepackaging medication in a separate container for each resident a week prior to administering. citations issued.
Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Last Earthquake drill was conducted on 6/13/26.
Residents with Special Health Needs: There are no residents using hospice services at this time.

- 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 and appeal rights were provided to Evangeline De Casa.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2026
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 07/16/2026 03:39 PM - It Cannot Be Edited


Created By: Tena Herrera On 07/16/2026 at 02:33 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 07/16/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as during tour LPA observed client bathroom in main bldg to have cleaning solutions/chemicals in an unlocked bathroom sink cabinet, additionally there were unlocked cleaning chemicals and roach spray in Room1, R2's physician report that states they cannot have access to cleaning chemicals or disinfectants, this poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/17/2026
Plan of Correction
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During visit Administrator removed cleaning solutions and roach spray from R2's room and stored in locked cabinet and locked the bathroom cabinet with cleaning solutions in main building.
Administrator/Licensee to retrain all staff on how to ensure all items which could pose a danger to residents are kept inaccessible to residents in care. and email LPA a copy of the training log with participant signatures by 7/30/26
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as during medication review LPA observed that R7 is missing 1 PRN medication, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/17/2026
Plan of Correction
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Administrator/Licensee to contact pharmacy and order medication on order for R7 and show proof of reorder and delivery date to LPA by 7/17/26. Additionally a staff training must be conducted on medication and how to properly assist residents with medication to avoid such errors. A copy of the training log with participant signatures must be emailed to LPA by 7/30/26
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Tena Herrera
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2026


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 07/16/2026 03:39 PM - It Cannot Be Edited


Created By: Tena Herrera On 07/16/2026 at 02:33 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 07/16/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87219(e)
Planned Activities
(e) In facilities licensed for sixteen (16) to forty-nine (49) persons, one staff member, designated by the administrator, shall have primary responsibility for the organization, conduct and evaluation of planned activities. This person shall have had at least six (6) month's experience in providing planned activities or have completed or be enrolled in an appropriate education or training program.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above as Administrator Stated that Staff #5 is the designated staff with the primary responsibility being to plan,prepare and conduct activities, however, after file review S5 does not have the proper training or education, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/30/2026
Plan of Correction
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Administrator/Licensee to either designate a qualified staff to be responsible for planned activites or provide S5 with the appropriate education or training program to qualify them for this responsibility. Proof of either or must be emailed to LPA by POC due date.
Type B
Section Cited
HSC
1569.69(g)
Other Provisions
(g) Residential care facilities for the elderly licensed to provide care for 16 or more persons shall maintain documentation that demonstrates that a consultant pharmacist or nurse has reviewed the facility’s medication management program and procedures at least twice a year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as per administrator the Veterans Affairs calls facility to do the medication review at least 2 times a year, however, they do not have any documentation of the review, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/30/2026
Plan of Correction
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Administrator to have a qualified pharmacist or nurse review facility's medication management and procedures and email a copy of the review to LPA by POC due date. (the pharmacist/nurse cannot be employed by facility or related to administrator/licensee as this creates a conflict of interest)
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Tena Herrera
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2026


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 07/16/2026 03:39 PM - It Cannot Be Edited


Created By: Tena Herrera On 07/16/2026 at 02:33 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 07/16/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(4)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as during medication review LPA observed 2 Residents Medications that were missing labels R6 and R7 are prescribed with a routine vitamin and the bottles do not have labels, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/30/2026
Plan of Correction
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Administrator/Licensee to contact pharmacy, obtain a copy of the label and place label on the medication, a photo of bottle with required label to be emailed to LPA by POC due date.
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as during medication review LPA observed trays with medication in small plastic cups, the medications (per administrator) are prepacked for the week in the small containers, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/30/2026
Plan of Correction
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LPA expalined that medication cannot be transfered from its original container, Administrator to review the regulation in its entirety once reviewed they must fill out, sign and date the POC Form (LIC9098) provided during visit and email a copy to LPA by POC due date, additonally Administrator is to develop a plan on how they will ensure they will stay in compliance with the regulation, retrain staff and email a copy of plan and training log to LPA.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Tena Herrera
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2026


LIC809 (FAS) - (06/04)
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