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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004738
Report Date: 07/09/2024
Date Signed: 07/09/2024 05:23:22 PM

Document Has Been Signed on 07/09/2024 05:23 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:CAMELLO HOME 1FACILITY NUMBER:
397004738
ADMINISTRATOR/
DIRECTOR:
CAMELLO, KIMBERLYFACILITY TYPE:
735
ADDRESS:2203 MICHIGAN AVENUETELEPHONE:
(209) 598-2036
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY: 5CENSUS: 2DATE:
07/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:01 PM
MET WITH:K. CamelloTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On 7/9/24, Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection. LPA met with Kim explained the purpose of the visit.
LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 107.5 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees.

Fire extinguishers and Smoke detectors are operational. LPA observed centrally stored medications are kept locked and inaccessible to residents. LPA reviewed and compared resident medications. LPA reviewed 2 resident and 2 staff files, including criminal record clearances. All staff are Fingerprint cleared and associated to the facility. First aid kit was checked and is complete. LPA observed a carbon monoxide detectors in the facility. Fire drill conducted on 7/2/2024.

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no deficiencies

Exit interview held, copy of report given.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/09/2024
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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