366408076-1-11-2024-56-AS-ACON-CZDV3P-20240111150506

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366408076
Report Date: 01/11/2024
Date Signed: 01/11/2024 03:05:16 PM

Document Has Been Signed on 01/11/2024 03:05 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	CAMEO ELDERLY CARE, INC.		FACILITY NUMBER:	366408076
ADMINISTRATOR:	LIDIA JUHASZ		FACILITY TYPE:	740
ADDRESS:	6879 CAMEO ST		TELEPHONE:	(909) 237-3635
CITY:	ALTA LOMA	STATE: CA	ZIP CODE:	91701
CAPACITY:	3	CENSUS:	DATE:	01/11/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Lydia Juhasz		TIME 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, Amber Coleman, (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 two. LPA observed that the facility is operating at the capacity and in the conditions approved by Community Care Licensing (CCL). Physical Plant: LPA Coleman observed the facility's temperature overall to be comfortable. 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. LPA observed the resident in room. The room was equipped with all required furniture such as beds with appropriate linens, night stands, seating, storage and lighting. LPA Coleman 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 12:55pm LPA inspected the facility's backyard and observed shovels, ladders and water hose left out. Additionally, LPA observed clutter obstructing the one pathway to be used for evacuation. Please see LIC9099-C

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024

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 01/11/2024 03:05 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, 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: 01/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

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 observations the licensee did not comply with the section cited above in by not verifying what canned goods were of good quality and expiration dates in good standing; which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/12/2024
	Plan of Correction
1 2 3 4	Administrator agrees to inspect the cabinet containing canned goods and removed all canned goods with expired dates. Administrator agrees to complete this task and submit a statement of understanding by way of the LIC9098 to Community Care Licensing within 30 business days.

Type B

Section Cited

CCR

87458(b)

Medical Assessment

(b) The medical assessment shall include, but not be limited to: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record reviews the licensee did not comply with the section cited above in not having a current client medical assessment on file for the resident; which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/11/2024
	Plan of Correction
1 2 3 4	Administrator agrees to assist the resident and/or their family members in making and keeping an appointment with the Primary Care Physician to complete the Physician's Report. Administrator agrees to submit verification of the completed Physician's Report and submit proof to the Community Care Licensing Office within 30 business days.

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: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/11/2024 03:05 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, 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: 01/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(c)

80087 Building and Grounds (c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations of the backyard the licensee did not comply with the section cited above by not ensuring that the passages ways for evacuation were clear and free of clutter which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/12/2024
	Plan of Correction
1 2 3 4	Administrator agrees to remove all items obstructing the side passageways. Items such as a metal bookcase, bags of clothing, yard tools and supplies should be moved and stored out of the evacuation route. Administrator agrees to complete this task and submit verification to the Community Care Licensing Office within 30 business days.

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: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024

LIC809 (FAS) - (06/04)

Page: 4 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CAMEO ELDERLY CARE, INC.	FACILITY NUMBER: 366408076
	VISIT DATE: 01/11/2024

NARRATIVE

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Food Service: Nonperishable and perishable food is sufficient for number of residents in care. At approximately 1:00pm LPA inspected the facility's non-perishable food supply and observed 3 canned goods which had expired. 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. According to staff records, all staff files contained verification of their annual training.
Record Review and Resident/Staff Files: LPA Coleman reviewed records for two residents. 1 Resident record was missing a current medical assessment. All other documents were observed to be current and in good standing. The remainder of the resident files are complete with physician reports and Needs and Services Plans. LPA Coleman additionally reviewed 2 staff files and confirmed that staff records reflect current CPR/First Aid Certification and Criminal Record Clearance.
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. Emergency Disaster Plan is current.
Medication/Medical Related Services: LPA observed that the residents' medication is centrally stored and securely in a file cabinet. LPA Coleman did not observe any medication errors at this time.

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: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024

LIC809 (FAS) - (06/04)

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