<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006238
Report Date: 09/30/2024
Date Signed: 09/30/2024 11:21:42 AM

Document Has Been Signed on 09/30/2024 11:21 AM - 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 CARE HOME 1FACILITY NUMBER:
306006238
ADMINISTRATOR/
DIRECTOR:		ANG, MERCEDITAFACILITY TYPE:
740
ADDRESS:2927 BONANZATELEPHONE:
(949) 369-8390
CITY:SAN CLEMENTESTATE: CAZIP CODE:
92673
CAPACITY: 6CENSUS: 6DATE:
09/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:30 AM
MET WITH:Mercy AngTIME VISIT/
INSPECTION COMPLETED:
11:50 AM
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) Kimberly Lyman conducted an unannounced visit to Camino Hills Care Home 1. 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 on hospice. Administrators Mercy Ang and Maria Cecelia Domingo arrived during the visit. Administrator Mercy Ang has an administrator certificate valid until 11/25/2024.
LPA Lyman along with Administrator Ang toured the facility at 8:01 AM. 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 six resident bedrooms, 1 common restroom, 4 resident restrooms, 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 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 74.6 and 143 degrees F in all facility bathrooms. 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 gates are 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. CONT ON LIC809-C DATED 09/30/2024
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2024
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
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 CARE HOME 1
FACILITY NUMBER: 306006238
VISIT DATE: 09/30/2024
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
26
27
28
29
30
31
32
Facility provided documentation of last fire drill conducted in July 2024. Facility provides activities in the form of exercise, and music therapy. LPA reviewed six 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 training 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, the following violation is being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report as well as appeal rights were discussed and provided with facility representative.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/30/2024 11:21 AM - It Cannot Be Edited


Created By: Kimberly Lyman On 09/30/2024 at 10:49 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: CAMINO HILLS CARE HOME 1
FACILITY NUMBER: 306006238

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)
Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. LPA observed water temperature to be out of compliance which poses a potential health and safety risk to persons in care.
POC Due Date: 10/14/2024
Plan of Correction
1
2
3
4
Licensee to adjust water temperature and 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:Alisa Ortiz
LICENSING EVALUATOR NAME:Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2024


LIC809 (FAS) - (06/04)
Page: 3 of 3