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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005179
Report Date: 01/09/2025
Date Signed: 01/09/2025 12:50:24 PM

Document Has Been Signed on 01/09/2025 12:50 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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:CAMELLIA WEST INCFACILITY NUMBER:
306005179
ADMINISTRATOR/
DIRECTOR:		COFFMAN, ROSARIOFACILITY TYPE:
735
ADDRESS:239 CAMELLIA STREETTELEPHONE:
(714) 943-5932
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 4CENSUS: 3DATE:
01/09/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Administrator - Mario AntonioTIME VISIT/
INSPECTION COMPLETED:
01:02 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dwayne Mason Jr. conducted an unannounced annual required visit. LPA arrived at the facility and was greeted by Administrator Mario Antonio and explained the nature of the visit. The facility is a one-story home with three client rooms, one client bathroom, one staff room, one staff bathroom, office, kitchen, dining room, living room, backyard with covered patio, laundry area and 2-car garage.

LPA observed the facility to be clean safe and sanitary in most rooms. Upon entry into the facility, LPA observed an excess of furniture (couches, shelves, tables) moved to the center of the living room and unused items in the backyard (bed frame, cardboard boxes) creating a potentially unsafe area for clients. A deficiency is being issued. All client rooms had the required elements, including bed, chair, closet space and ample lighting. Facility has extra linens and hygiene supplies for residents in hallway cabinets. Restrooms are stocked with soap and paper towels. Hot water measured below 105 degrees F. A deficiency is being issued. LPA observed emergency food and water supply. LPA observed the fire extinguisher was serviced on 9/3/2024. Smoke/Carbon Monoxide detector were tested and noted as operational. LPA observed hazardous items such as knives, chemicals and cleaners to be locked up in the laundry area and garage. Medication for each resident is kept locked in a cabinet in the kitchen. Exit gate is unlocked and self-latching. LPA observed exit gates to be unobstructed. LPA reviewed all three client files. Client files contained all the necessary elements. LPA reviewed two staff files. LPA observed no health screenings in the staff files. A Technical Violation (TV) is being issued. Based on record review, LPA observed the facility does not have the following: an infection control plan, a completed emergency disaster plan or record of 4 quarterly drills within the last year. Three deficiencies are being issued. LPA also reviewed P&I and medication for three clients.

Based on the observation made during today’s visit, five deficiencies and a technical violation are being issued per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with facility staff and a copy was provided to the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2025
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 5
Document Has Been Signed on 01/09/2025 12:50 PM - It Cannot Be Edited


Created By: Dwayne L Mason On 01/09/2025 at 11:49 AM
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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CAMELLIA WEST INC
FACILITY NUMBER: 306005179

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(a)
Infection Control Requirements
(a) A licensee shall ensure that infection control practices are maintained as follows:

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 due to the absence of a completed Infection Control Plan.
POC Due Date: 01/23/2025
Plan of Correction
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4
Administrator stated they would draft a complete Infection Control Plan (LIC9282) and submit it to LPA via email by the assigned POC due date.
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observations, the licensee did not comply with the section cited above due to the presence of furniture (couches, shelves, a bed frame, tables) moved to the center of the living room and other items and unused items (posters, vaccuum cleaner, cardboard boxes) being stored in the living room and backyard.
POC Due Date: 01/16/2025
Plan of Correction
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Administrator stated they would either move furniture out of the way in the living room and remove unused items from the living room and backyard by the assigned POC due date.
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:Armando J Lucero
LICENSING EVALUATOR NAME:Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2025


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 01/09/2025 12:50 PM - It Cannot Be Edited


Created By: Dwayne L Mason On 01/09/2025 at 11:49 AM
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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CAMELLIA WEST INC
FACILITY NUMBER: 306005179

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, the licensee did not comply with the section cited above due to the temperature of the shower water in the client's bathroom remaining under 105 degrees F.
POC Due Date: 01/23/2025
Plan of Correction
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Administrator stated they would have a professional plumber come and look at the facility's hot water heater to assess the water temperature in the bathroom and come up with a solution for the water temperature being low. Administrator stated they will work with the plumber to solve the problem by the assigned POC due date. AD stated they will notify LPA by the assigned POC due date if there are limitations or if the facility requires an extension to solve the problem
Type B
Section Cited
HSC
1565(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 individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, 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 record review, the licensee did not comply with the section cited above due to the absence of records for 2 out of 4 quarterly disaster drills in 2024.
POC Due Date: 01/23/2025
Plan of Correction
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Administrator stated they will provide LPA with a list of projected dates on which the facility will conduct their quarterly disaster drills in 2025 via email by the assigned POC due date. LPA stated the drills do not have to occur on the exact dates provided to the LPA, but reminded the AD that the drills must occur quarterly.
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:Armando J Lucero
LICENSING EVALUATOR NAME:Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 01/09/2025 12:50 PM - It Cannot Be Edited


Created By: Dwayne L Mason On 01/09/2025 at 11:49 AM
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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CAMELLIA WEST INC
FACILITY NUMBER: 306005179

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80023(a)
Disaster & Mass Casualty Plan
(a) Each licensee shall have and maintain on file a current, written disaster and mass casualty plan of action.

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 due to the presence of an incomplete Emergency Disaster Plan.
POC Due Date: 01/16/2025
Plan of Correction
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Administrator stated they would complete all questions in the Emergency Disaster Plan and email the completed plan to the LPA by the assigned POC due date.
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:Armando J Lucero
LICENSING EVALUATOR NAME:Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2025


LIC809 (FAS) - (06/04)
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