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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004738
Report Date: 01/29/2025
Date Signed: 02/19/2025 11:36:21 AM

Document Has Been Signed on 02/19/2025 11:36 AM - 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:
01/29/2025
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:53 PM
MET WITH:K.CamelloTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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An office meeting was held on 1/29/2025 at 1pm on a Microsoft Teams Meeting video conferencing system review the stipulation. This Stipulation shall be posted in a conspicuous place at the facility for the duration of the probationary period.

The following were in attendance: Regional Manager (RM) Stephenie Doub, Licensing Program Manager (LPM) Lisa Rios, Licensing Program (LPA) Albert Johnson, Administrator/ Licensee Kim Camello.

LPA Johnson and LPM Rios went over and read the Stipulation and Waiver; Order, in it's entirety, to all persons present.

Items discussed at the meeting included, but not limited to:
Stipulation contents:
· Findings
· Revocation of Licenses and Administrator Certificates/License Application Denials – Not Stayed
· Exclusions- Not Stayed
· Revocations of Licenses and Administrator Certificates/License Application Denials -Stayed with Probation
· Stay of Revocation of Licenses and Administrator Certificate and Exclusion to Facilitate Sale of Facilities
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2025
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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: CAMELLO HOME 1
FACILITY NUMBER: 397004738
VISIT DATE: 01/29/2025
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Future Application for License, Registration, Certification or Approval
· Licensure, Certification or Approval; Application Denial, Tolling of Probationary Period
· Completion of Probation
· Violation of Stipulation Term
· Department's Authority
· Monitoring Fee
· Waiver of Hearing Rights; Waiver of Appeal/Modification Rights/Waiver of Claims
· Severable terms
· Public Records
· Signatures
· Counterparts
· Effective Date: (10/25/2024 – 10/25/2026)
· No Oral Modification
The Licensees/Respondents/Representatives stated they would abide by the following:
· Abide by the contents/terms of the Stipulation (submit all documents timely)
· Operate the facility in strict compliance with the regulations and statues governing the operation of a residential care facility for adults.
CCLD will do the following:
· Increase monitoring

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations cited during this visit. An exit interview was conducted, and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
LIC809 (FAS) - (06/04)
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