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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700197
Report Date: 11/07/2024
Date Signed: 11/07/2024 04:46:29 PM

Document Has Been Signed on 11/07/2024 04:46 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:CAMELOT CARE BUCKS HARBORFACILITY NUMBER:
342700197
ADMINISTRATOR/
DIRECTOR:		CANTILLER, ARACELIFACILITY TYPE:
740
ADDRESS:8006 BUCKS HARBOR WAYTELEPHONE:
(916) 659-5491
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
11/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Jane AragonTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On 11/7/24 at 1:45pm Licensing Program Analyst (LPA) Kevin Gould arrived at Camelot Care Bucks Harbor for the purpose of conducting a required 1 year annual inspection. LPA met with staff, Jane Aragon and together conducted a tour of the home.

LPA and Administrator evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor, clean and in good repair. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility.

LPA measured the water temperature, temperature measured at 104.5 degrees F which meets the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications secure from residents.

LPA observed the facility is not in compliance with fire clearance as they currently have one resident who's physician has identified as bedridden and the facility does not have a bedridden fire clearance. LPA also observed while reviewing staff files that two of the three staff files reviewed showed staff members were short of the required 8 hours of dementia care training as LPA only observed 5 hours each.

Per California Code of Regulations, Title 22 the following deficiencies are cited during today's inspection. An immediate civil penalty was issued during todays inspection. An exit interview was conducted, and a copy of this report and appeal rights were left at the facility.
Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
Kevin GouldTELEPHONE: (619) 672-5924
DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2024
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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Document Has Been Signed on 11/07/2024 04:46 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: CAMELOT CARE BUCKS HARBOR
FACILITY NUMBER: 342700197

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of resident records, the licensee did not comply with the section cited above as LPA observed one resident's physician report identified the resident as bedridden which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/08/2024
Plan of Correction
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Licensee will become complaint with fire clearance, Licensee feels the designation was done in error and will schedule an appointment with the resident's physician by the POC Due date and complete a written plan of correction detailing the steps the facility will take to ensure compliance title 22 regulations.
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.
Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
Kevin GouldTELEPHONE: (619) 672-5924

DATE: 11/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2024

LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 11/07/2024 04:46 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: CAMELOT CARE BUCKS HARBOR
FACILITY NUMBER: 342700197

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of staff files, the licensee did not comply with the section cited above as two staff files reviewed revealed two staff members only have 5 for the required 8 hours of annual training for dementia care which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/21/2024
Plan of Correction
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staff have agreed to have completed the additional three hours of dementia care training by the 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.
Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
Kevin GouldTELEPHONE: (619) 672-5924

DATE: 11/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2024

LIC809 (FAS) - (06/04)
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