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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000734
Report Date: 05/29/2024
Date Signed: 05/29/2024 12:17:56 PM


Document Has Been Signed on 05/29/2024 12:17 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:CAMEO HOMES - LIGHTHOUSEFACILITY NUMBER:
306000734
ADMINISTRATOR:LISE BRICKFACILITY TYPE:
740
ADDRESS:2512 LIGHTHOUSE LANETELEPHONE:
(949) 644-2740
CITY:CORONA DEL MARSTATE: CAZIP CODE:
92625
CAPACITY:6CENSUS: 3DATE:
05/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Lise Brick, Licensee & Rose Manabat Palma, AdministratorTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPA was greeted and granted entry by Maria Janet Manlutac, Caregiver. During today’s visit, LPA met with Lise Brick, Licensee (LE) and Rose Manabat Palma, Administrator (AD).

The facility is a single story building with an approved fire clearance of six non-ambulatory residents of which six may be on hospice. The facility currently has a census of three residents in care with one resident on hospice.

During today’s visit, LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors, testing hot water temperatures in three of three resident bathrooms, and testing auditory devices on all exits. The hot water temperature measured between 106.1 and 109.0 degrees Fahrenheit and all smoke detectors were operational. Fire extinguisher was charged and serviced on February 8, 2024. The PUB 475 poster was displayed and the correct size.

The facility does not have a fire drill on file for 2024. AD Palma will conduct a fire drill the first week of June. LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. LPA observed medication storage and reviewed the centrally stored medications. Per review completed medications appear to be being given as prescribed.

LPA reviewed three of four staff training and fingerprint records and conducted a complete review of resident records. LPA interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that both administrators have current administrators' certificates. LE and AD rotate staff from other nearby facilities and will associate all staff to all three of her homes. All staff were fingerprinted and cleared.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: RoseMarie RuppertTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2024
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


Document Has Been Signed on 05/29/2024 12:17 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: CAMEO HOMES - LIGHTHOUSE
FACILITY NUMBER: 306000734

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA interview and record review the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/07/2024
Plan of Correction
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AD Rose Manubat Palma will conduct a fire drill in the coming week and send proof of training and attendee roster to LPA Ruppert.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: RoseMarie RuppertTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 05/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: CAMEO HOMES - LIGHTHOUSE
FACILITY NUMBER: 306000734
VISIT DATE: 05/29/2024
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The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations.
An exit interview was conducted with Rose Manabat Palma and a copy of this report was given to the facility along with a copy of the LIC 858; 859;809-D and Appeal Rights.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: RoseMarie RuppertTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024
LIC809 (FAS) - (06/04)
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