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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003549
Report Date: 12/17/2024
Date Signed: 12/17/2024 03:35:20 PM

Document Has Been Signed on 12/17/2024 03:35 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:CAMINO HILLS OF SAN CLEMENTEFACILITY NUMBER:
306003549
ADMINISTRATOR/
DIRECTOR:		MARIA LAFIGUERAFACILITY TYPE:
740
ADDRESS:2924 ARROYOTELEPHONE:
(949) 369-9487
CITY:SAN CLEMENTESTATE: CAZIP CODE:
92673
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
12/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:55 AM
MET WITH:Maria Cecelia DomingoTIME VISIT/
INSPECTION COMPLETED:
03:10 PM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit to Camino Hills of San Clemente. The purpose of today’s visit was to conduct the Annual Required inspection. LPA was allowed entry into the facility and explained the reason for the visit. Facility is licensed for 6 bedridden residents. Facility has an approved hospice waiver for 6 residents and the home currently has 4 residents with 4 on hospice. Administrators Mercy Ang and Maria Cecelia Domingo arrived during the visit. Administrator Maria Cecelia Domingo has a current administrator certificate expiring on 07/11/2026.
LPA Lyman along with Administrator Domingo toured the facility at 12:17 PM. LPA toured the physical plant, checked food service, first aid kit and reviewed records. Facility appears to be clean, safe, and sanitary. The home consists of five resident bedrooms, 1 common restroom, 1 resident restroom, living room, dining room, and kitchen. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident rooms are single and double occupancy. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 105.2 and 110.6 degrees F in all facility restrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. Auditory exit alarms were operational during today's visit. First aid kit had all the elements including thermometer, tweezers and scissors. LPA observed toxins are secured during today's visit. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Smoke detectors and carbon monoxide detectors tested operational during today's visit. Fire extinguishers are fully charged. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample shaded seating for residents. Exit gate is unlocked and operational. LPA observed ample emergency food and water supply. LPA reviewed the emergency disaster plan and infection control and plans are thorough and complete. Facility provided documentation of last fire drill conducted on 10/15/2024.
CONTINUED ON LIC 809C DATED 12/17/2024.
Alisa OrtizTELEPHONE: (714) 703-2855
Kimberly LymanTELEPHONE: (714) 795-1497
DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2024
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: CAMINO HILLS OF SAN CLEMENTE
FACILITY NUMBER: 306003549
VISIT DATE: 12/17/2024
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Facility provides activities in the form of exercise, and music therapy. LPA reviewed four resident files and three staff files. Resident files contained required documents including admission agreements, physician reports and resident appraisals. Staff files reviewed contained required documentation of medical clearance/ TB, CPR and criminal record clearance as well as required training. LPA reviewed medication storage and administration. Medications are stored in a locked cabinet. Medications are being administered per physician order.











Based on the observations made during today's visit, NO deficiencies are being cited. Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
LIC809 (FAS) - (06/04)
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