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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374601463
Report Date: 10/24/2022
Date Signed: 10/24/2022 12:26:33 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/29/2022 and conducted by Evaluator Chinwe Nwogene
COMPLAINT CONTROL NUMBER: 18-AS-20220729121755
FACILITY NAME:CAMELOTFACILITY NUMBER:
374601463
ADMINISTRATOR:MOSS, JUDITHFACILITY TYPE:
735
ADDRESS:2035 ALTA VISTA DRIVETELEPHONE:
(760) 724-7898
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY:6CENSUS: 5DATE:
10/24/2022
UNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Judith Moss, LicenseeTIME COMPLETED:
12:35 PM
ALLEGATION(S):
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Facility grounds are in disrepair.
Facility is malodorous.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Chinwe Nwogene conducted an unannounced visit to conclude a complaint investigation into the allegation listed above. LPA met with Licensee, Judith Moss and Caregiver, Rachel Alvarez and discussed the purpose of the visit. During the investigation LPA interviewed Residents and staff.
Regarding the allegation “Facility grounds are in disrepair”. During LPA Nwogene’s visited the facility on 8/1/20222, LPA observed the right gate leading to the backyard was broken and a shed that was built behind the gate was being used as a storage. LPA interviewed Licensee, Judith Moss who stated the shed was being used as a storage but will be cleared and the gate repaired. Civil penalty will be accessed.
Regarding the allegation “Facility is malodorous.” LPA interviewed residents, the Interview with resident revealed facility has an older dog that is unable to go outside therefore peeing in the house. LPA observed facility had four #4 dogs living in the home. LPA observed the home to be odorous with dog pee and flies. LPA interviewed Licensee, Judith Moss who stated the dogs are therapy dogs but will inform the cleaner to use Lysol to clean and the rug in the dinning will be removed to help eliminate the odor.
Based on LPA's observation, and interviews conducted the preponderance of evidence standard has been met. Therefore, the above allegation(s) are found to be substantiated. California Code of Regulations (Title 22, Division & Chapter number 6) are being cited on the attached LIC 9099D). An exit interview was conducted with Rachel Alvarez in which a copy of this report was discussed with and provided along with copies of the LIC421IM, and Appeal Rights.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 18-AS-20220729121755
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CAMELOT
FACILITY NUMBER: 374601463
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/03/2022
Section Cited
CCR
80087(a)
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(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.

(1) The licensee shall take measures to keep the facility free of flies and other insects.
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Judith Moss stated the cleaner will use Lysol to clean and the rug in the dining will be removed to help eliminate the odor.
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This requirement is not met based as evidence by observation, and interview. The licensee did not compy with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
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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.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20220729121755
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CAMELOT
FACILITY NUMBER: 374601463
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/25/2022
Section Cited
CCR
80087(c)
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80087(c)

(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction
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Judith Moss stated the shed will be cleared and the gate fixed.
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This requirement is not met based as evidence by observation, and interview. The licensee did not compy with the section cited above using the shed built behind the gate leading to the backyard as storage which poses a potential health, safety or personal rights risk to persons in care.
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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.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3