306001914-7-19-2022-22-AS-JCHO-CGGUX8-20220719155755

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306001914
Report Date: 07/19/2022
Date Signed: 07/19/2022 03:58:03 PM

Document Has Been Signed on 07/19/2022 03:58 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	CAMEO HOMES - EASTSIDE I		FACILITY NUMBER:	306001914
ADMINISTRATOR:	LISE BRICK		FACILITY TYPE:	740
ADDRESS:	236 EAST 20TH STREET		TELEPHONE:	(949) 939-3935
CITY:	COSTA MESA	STATE: CA	ZIP CODE:	92627
CAPACITY:	6	CENSUS: 3	DATE:	07/19/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:57 PM
MET WITH:	Lise Brick		TIME COMPLETED:	04:20 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) Jessica Cho conducted an unannounced visit to Cameo Homes- Eastside I. The purpose of today's visit was to conduct a Required 1 Year inspection focusing primarily on Infection Control. At 1:05 pm, LPA Cho was allowed entry into the facility and met with Caregiver (CG) Redina Diaz after completing the Coronavirus 2019 (COVID-19) screening procedure. Caregiver Joberd Suede was also present along with Administrator (Admin) Lise Brick. As of today, there are no active COVID-19 cases in the facility. Facility screens and documents temperature for all visitors on a sign in sheet. LPA observed the required COVID-19 precautionary signs posted on the front door. The facility is licensed for six non-ambulatory residents. The facility also has a Hospice waiver for two residents. There are currently six residents living in the facility of which four are in hospice care. Admin Brick stated that a hospice waiver increase of was requested at the suggestion of LPA Lydia Martinez many years ago. Upon facility history review, Cameo Homes- Lighthouse was one out of the three facilities approved for a hospice waiver increase. Around 1:15 pm, LPA Cho conducted a tour of the physical plant along with CG Suede and Admin Brick. The single story home consists of five resident bedrooms and two bathrooms. The facility also has a living room, dining area, and kitchen. The six residents in the facility appeared well-groomed and well cared-for. LPA Cho observed the Complaint Poster in the correct size. The resident bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, showers were free of mold/mildew and a non-skid surface or mat was in place. Resident bath towels and personal hygiene supplies were adequately stocked including paper towels and hand soaps. The required hand washing signs were observed in the bathrooms. LPA Cho tested the hot water temperature in the resident bathrooms and the temperature measured at 106.7 degrees Fahrenheit in Bathroom #1 and 105.0 degrees Fahrenheit in Bathroom #2.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022

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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CAMEO HOMES - EASTSIDE I	FACILITY NUMBER: 306001914
	VISIT DATE: 07/19/2022

NARRATIVE

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LPA Cho inspected the kitchen along with CG Suede and Admin Brick. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. The two fire extinguishers were fully charged. The smoke and carbon monoxide detectors were tested along with Admin Brick and CG Suede and were found to be operational. Medications, toxins, and sharps were locked and inaccessible to residents. The auditory alarms throughout the facility were in operating condition.

LPA Cho along with Admin Brick toured the outside grounds. There were no bodies of water present. LPA observed a gated chicken coop on the lawn. There was shading and sufficient seating for residents. Walkways around the home were clear of hazards and the side gates were self-closing and self-latching. There were no security bars or weapons on the premises.

LPA Cho reviewed the Emergency and Disaster Plan for Residential Care Facilities for the Elderly (LIC610E). Facility has a plan for COVID-19 testing residents and staff as well as a plan for isolation as needed. Facility has back-up emergency food and water supply stored in the garage. The First Aid Kit had all the required components except the first aid manual, and the facility had sufficient PPEs.

LPA Cho reviewed Assembly Bill 665. This bill would require residential facilities serving adults, residential care facilities for persons with chronic life-threatening illness, and residential care facilities for the elderly with existing internet service to provide at least one internet access device that can support real-time interactive applications, is equipped with video conferencing technology, and is dedicated for client or resident use. A smart phone is provided to residents upon request.

LPA Cho reviewed the approved COVID-19 mitigation plan of the facility. A deficiency is being cited in this review as per Title 22 Division 6 of the California Code of Regulations. Advisory Notes (LIC9102) were also issued during the visit, and the licensee will follow-up with the corrections. Due to the time constraints of Administrator Lise Brick, Administrator authorized Caregiver Joberd Suede to sign the reports. An exit interview was conducted with Caregiver Joberd Suede, and a copy of this report was provided.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022

LIC809 (FAS) - (06/04)

Page: 2 of 5

Document Has Been Signed on 07/19/2022 03:58 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CAMEO HOMES - EASTSIDE I	FACILITY NUMBER: 306001914
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87204(a)

A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity.
	Deficient Practice Statement
1 2 3 4	This requirement is not met as evidenced by: Based on observation and Administrators' interviews', the facility is operating beyond the maximum number of persons who may receive hospice servies at one time. Facility has a hospice waiver for 2 but 4 residents in hospice care were observed at this time. This poses a potential health and safety risks to persons in care.
	POC Due Date: 07/26/2022
	Plan of Correction
1 2 3 4	Licensee agrees to submit an increase of hospice waiver request and to forward proof to 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: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022

LIC809 (FAS) - (06/04)

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