366408076-2-21-2025-56-AS-LFAW-DE4UXS-20250221145848

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366408076
Report Date: 02/21/2025
Date Signed: 02/21/2025 02:59:21 PM

Document Has Been Signed on 02/21/2025 02:59 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	CAMEO ELDERLY CARE, INC.		FACILITY NUMBER:	366408076
ADMINISTRATOR/ DIRECTOR:	LIDIA JUHASZ		FACILITY TYPE:	740
ADDRESS:	6879 CAMEO ST		TELEPHONE:	(909) 237-3635
CITY:	ALTA LOMA	STATE: CA	ZIP CODE:	91701
CAPACITY: 3	TOTAL ENROLLED CHILDREN: 0	CENSUS: 1	DATE:	02/21/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Lidia Juhasz, Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:10 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, LaVette Farlow, (LPA) arrived at the Cameo Elderly Facility unannounced to conduct an Annual Inspection. LPA was greeted by Administrator, Lidia Juhasz. LPA introduced self and stated purpose of the visit. LPA was granted entry and provided space to work. LPA was accompanied by Administrator, Lidia Juhasz and conducted a tour of the facility, inside and outside, and observed the following: Facility: The Facility is licensed three, non-ambulatory residents, 1 bedridden resident and Hospice Waiver for two. Administrator reported that the current census is one. LPA observed that the facility is operating at the capacity and in the conditions approved by Community Care Licensing (CCL). Physical Plant: At 10:00 AM LPA Farlow observed the facility's temperature overall to be comfortable 68 Degrees Fahrenheit. Various lighting fixtures and lamps were observed throughout the facility for the purposes of safety. lighting and lamps make for appropriate lighting to ensure residents comfort and safety. The facility is equipped with smoke alarms, carbon monoxide detectors and fire extinguishers which were tested and found operable. At 10:15am, while testing the smoke alarms and carbon monoxide LPA observed the licensee taking the carbon monoxide alarm out of the residents drawer. A deficiency issued. LPA observed the resident in room. Please see LIC9099-C

Nedra Brown	TELEPHONE: (951) 202-5776
Lavette Farlow	TELEPHONE: 951-248-0304
	DATE: 02/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025

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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CAMEO ELDERLY CARE, INC.	FACILITY NUMBER: 366408076
	VISIT DATE: 02/21/2025

NARRATIVE

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The room was equipped with all required furniture such as beds with appropriate linens, night stands, seating, storage and lighting. At 10:20am, LPA tested the water temperature in the 2 out of 2 bathroom in the home and observed the water temperature was out of range testing at 135.2 and 130.2 degrees Fahrenheit. A deficiency was issued. LPA Farlow reviewed the facility's Emergency Disaster Plan and facility sketch posted in a prominent place. LPA observed no pool or body of water on facility grounds. At approximately 11:00am LPA inspected the facility's backyard and branches in the backyard. Licensee stated she had worker there cleaning the yard. LPA did not observed any items blocking the pathway.
Food Service: Nonperishable and perishable food is sufficient for number of residents in care. At approximately 10:20 am LPA inspected the facility's non-perishable food supply and observed 5 canned goods which had expired. A deficiency was issued. LPA observed the facility kitchen. Food is being prepared and stored properly. Facility has a variety of food available for residents. LPA verified that sharps, chemicals and cleaning supplies were stored securely, inaccessible to residents.
Care & Supervision: Facility has sufficient care staff; who assist residents 24 hours and 7 days a week.
Record Review and Resident/Staff Files: At approximately 10:45am, LPA Farlow reviewed records for one residents. 1 Resident record all documents were observed to be current and up to date. Resident file is complete with physician reports and Needs and Services Plans. LPA Farlow requested 3 staff files. Licensee could not locate one staff file. The two additional files were incomplete missing CPR/First Aid Certification. A deficiency issued. All staff and adults living in the home have completed a background clearance through guardian website.

Please see LIC9099-C

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Lavette Farlow	TELEPHONE: 951-248-0304
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025

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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CAMEO ELDERLY CARE, INC.	FACILITY NUMBER: 366408076
	VISIT DATE: 02/21/2025

NARRATIVE

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Administration: Disaster Plan, Resident Rights, Theft and Loss Policy, House Rules, Facility Sketch, Ombudsman poster, Administrator Certificate, Personal Rights and facility license are posted in the hallway of the facility. LPA observed the LIC 610E Emergency Disaster Plan was expired and was not reviewed annually. Also, the licensee did not conduct regular fire and disaster drills and does not have a Infection control plan available for review. A deficiency and technical violation issued.
Medication/Medical Related Services: LPA observed that the residents' medication is centrally stored and securely in a file cabinet. LPA Farlow observed that Licensee had not completed the daily charting for the residents medication on the MARS. A deficiency was issued.

Based on observations and record reviews, Deficiencies and Technical Violations are being cited to address the above mentioned concerns. Exit interview conducted and copy of this report was provided to Administrator/Licensee Lidia Juhasz.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Lavette Farlow	TELEPHONE: 951-248-0304
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/21/2025 02:59 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CAMEO ELDERLY CARE, INC.	FACILITY NUMBER: 366408076
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

HSC

1569.311

Regulations

Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, and interview, the licensee did not comply with the section cited above by not ensuring that the facility has a active working carbon monoxide alarm in the home which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/28/2025
	Plan of Correction
1 2 3 4	Licensee agrees to purchase a sufficient amount of carbon monoxide detectors for the home by POC date and provide a receipt showing proof of purchase. Licensee agrees to review the regulation and provide LPA with a statement acknowledging, and review of the regulation by POC date.

Type A

Section Cited

CCR

87411(d)

Personnel Requirements - General

(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above by not ensuring 3 out of 3 staff are CPR trained, complete annual training on the current procedures to care for residents and maintaining a current personnel file for each staff member, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/21/2025
	Plan of Correction
1 2 3 4	Licensee agrees to complete and update all staff personnel files and records. Licensee will ensure that all staff have current CPR/First Aid training, conduct annual training and documentation in their personnel file or staff training folder.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Nedra Brown	TELEPHONE: (951) 202-5776
Lavette Farlow	TELEPHONE: 951-248-0304
	DATE: 02/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/21/2025 02:59 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CAMEO ELDERLY CARE, INC.	FACILITY NUMBER: 366408076
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87555(b)(8)

General Food Service Requirements

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, and interview, the licensee did not comply with the section cited above by not conducting a regular inventory of the nonperishable food item and ensuring that they are not expired which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/28/2025
	Plan of Correction
1 2 3 4	Licensee agrees to review the regualtion and complete a statement acknowledging review of the regulation. Licensee also, agrees to conduct an inventory of the food supply to ensure all expired food is destroyed by POC.

Type A

Section Cited

CCR

87465(d)(3)

Incidental Medical and Dental Care Services

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above by not ensuring that the residents MARS for 1 out of 1 residents file is completed and accurate with dates and time when medication is dispensed which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/07/2025
	Plan of Correction
1 2 3 4	Licensee agrees to create a new log documenting date and time medication is issued. Licensee will complete a training for staff as well. Licensee agrees to provide a training log by POC 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.

Nedra Brown	TELEPHONE: (951) 202-5776
Lavette Farlow	TELEPHONE: 951-248-0304
	DATE: 02/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025

LIC809 (FAS) - (06/04)

Page: 3 of 7

Document Has Been Signed on 02/21/2025 02:59 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CAMEO ELDERLY CARE, INC.	FACILITY NUMBER: 366408076
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87470(c)

Infection Control Requirements

(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring they have a current Infection control plan for the staff and resident in care, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/14/2025
	Plan of Correction
1 2 3 4	Licensee agrees to provide proof of infection control plan and maintain a current folder in the home by POC date and at all times.

Type B

Section Cited

CCR

87303(e)(3)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above by not ensuring the water temperature in maintained in the home. The water measure at 135.2 and 130.2 degrees Fahrenheit which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/28/2025
	Plan of Correction
1 2 3 4	Licensee will conduct a tempterature check three times a day for 7 days and will provide documents of the measuements by POC 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.

Nedra Brown	TELEPHONE: (951) 202-5776
Lavette Farlow	TELEPHONE: 951-248-0304
	DATE: 02/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025

LIC809 (FAS) - (06/04)

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