397004738-1-24-2023-27-AS-MBIR-CNDRFR-20230124115934

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 397004738
Report Date: 01/24/2023
Date Signed: 01/24/2023 12:00:55 PM

Document Has Been Signed on 01/24/2023 12:00 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	CAMELLO HOME 1		FACILITY NUMBER:	397004738
ADMINISTRATOR:	CAMELLO, KIMBERLY		FACILITY TYPE:	735
ADDRESS:	2203 MICHIGAN AVENUE		TELEPHONE:	(209) 598-2036
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95204
CAPACITY: 5		CENSUS: 3	DATE:	01/24/2023
TYPE OF VISIT:	Case Management - Legal/Non-compliance	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Kimberly Camello		TIME COMPLETED:	11:25 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	On 1-24-23 at 10:00am, a Non-Compliance Conference (NCC) was conducted in the Sacramento South Regional Office (RO) via Microsoft Teams. The purpose of this Non-Compliance Conference meeting was to follow up on a previous citation issued to facility following the death of a resident. Present in the meeting were Regional Manager (RM) Stephanie Doub, Licensing Program Manager (LPM) Liza King, Licensing Licensing Program Analyst (LPA) Michael Bilger, Licensee Kimberly Camello, facility trainer Steve Campbell, Regional Center representatives Brian Bennett and Rukaiyah Jones, and Ombudsman Kathryn Thomas. The Non-Compliance Conference process was explained during this meeting to include the Administrative Process. On 1-6-23, Licensee was issued a citation under Title 22 section 80078(a) Responsibility for Providing Care and Supervision. (a).The licensee shall provide care and supervision as necessary to meet the client’s needs due to licensee not ensuring necessary and timely care and supervision as a safety measure for R1 which lead to choking and death of resident1 (R1). The event which resulted in the citation noted above was discussed between Licensee, Regional office, and Regional center and included: A plan ensuring appropriate supervision based on residents’ specific needs Physical plant layout including access to areas in the facility to ensure resident safety including bedrooms and bathrooms. Training by outside certified vendors on the topic of care and supervision, dietary orders, and timely medical attention. {Cont. on 809C}

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2023

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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: CAMELLO HOME 1	FACILITY NUMBER: 397004738
	VISIT DATE: 01/24/2023

NARRATIVE

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Incidental Medical Care plan updates - timely medical attention provided to residents as necessary including recognizing the need for medical intervention and acting accordingly to ensure the safety of residents in care.

Care and Supervision procedures related to on-duty staff as well as Administrator availability.

During the meeting on 1/24/2023, the licensee agreed to the following:

1. Increased presence of the Administrator at the facility 40 hours a week

2. Submission of plan for on-going training including training dates on care and supervision procedures, timely medical attention and following dietary orders and knowledge of dietary modifications by 1-31-23.

3. Submission of plan for ensuring all staff have access to keys at all times including location of keys and availability. Plan to be submitted by 1-31-23

4. Submission of plan ensuring staff have knowledge of residents’ needs by 1-31-23

5. Submission of plan for monitoring individualized care plans regarding resident preference for locked doors by 1-31-23

6. Arrange for dietician to conduct staff training on dietary needs and precautions regarding swallowing and choking. Also to review dietician’s report and update care plans of residents as needed. Training date to be submitted by 1-31-23

7. Licensee to continue with annual staff training and on-going training as needed.

{Cont. on 809C}

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2023

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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: CAMELLO HOME 1	FACILITY NUMBER: 397004738
	VISIT DATE: 01/24/2023

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8. Submission of LIC 500 Personnel Summary for facility to include the Administrator presence by 1-25-23

9. Submission of LIC 308 Designation of person(s) in charge in the absence of the Administrator by 1-25-23

10. Licensee to ensure updated plan for Incidental Medical Care to include timely medical attention and need for 9-1-1 intervention by 1-31-23.

11. Licensee to submit a plan to ensure appropriate access to locked doors as necessary in the event of an emergency and needed medical attention by 1-25-23.

12. Licensee has agreed to accept Departments Technical Support Program (TSP) for additional assistance with compliance.

In addition, the Regional Office will continue with unannounced quarterly visits to monitor the above and overall compliance.

Licensee was made aware that completing the non-compliance conference does not deprive the Department of its authority to take appropriate formal legal action under the Health and Safety Codes if such action is deemed necessary by the Regional Manager.

Licensee was made aware that in the event the Department determines that the licensee has violated the laws/regulations or is inadequately implementing the approved plans, the Department, in its discretion, may seek formal legal action or other appropriate administrative action.

The RO will revisit compliance in 9-12 months and begin the legal process if facility is not in compliance.

An exit interview was conducted with licensee Kimberly Camello and a copy of this report was emailed to Kimberly with a request for return with signature by 1-25-23 to Michael.Bilger@dss.ca.gov.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2023

LIC809 (FAS) - (06/04)

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