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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 397004738
Report Date: 01/06/2023
Date Signed: 01/06/2023 11:27:09 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/13/2022 and conducted by Evaluator Michael Bilger
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220913143824
FACILITY NAME:CAMELLO HOME 1FACILITY NUMBER:
397004738
ADMINISTRATOR:CAMELLO, KIMBERLYFACILITY TYPE:
735
ADDRESS:2203 MICHIGAN AVENUETELEPHONE:
(209) 598-2036
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY:5CENSUS: 3DATE:
01/06/2023
UNANNOUNCEDTIME BEGAN:
10:17 AM
MET WITH:Kimberly CamelloTIME COMPLETED:
11:35 AM
ALLEGATION(S):
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Facility failed to provide supervision resulting in resident choking and death
INVESTIGATION FINDINGS:
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On 1-6-23 at 10:17am, Licensing Program Analyst (LPA) Michael Bilger conducted an unannounced visit to facility to deliver findings for the complaint allegation noted above. LPA met with Licensee Kimberly Camello and explained the purpose of the visit. During the course of this investigation, the Department conducted interviews with Staff1 (S1), S2, S3, and S4. The Department also conducted interviews with Resident2 (R2), R3, and R4. Additional witnesses were also interviewed. The department also reviewed medical records, coroner’s report, death certificate pertaining to R1 in addition to other facility file documenation. Facility photographs were also reviewed as part of this investigation.
Based on interviews and record reviews, it was determined that on 2-14-21, R1 was sitting at the dining table with staff and other residents and observed by staff to be coughing with presence of mucus and saliva coming from R1’s mouth. R1 ran to the bathroom and locked the door. Through interviews conducted, it was further determined that R1 was not assessed for safety and medical attention between a period of 7-9 minutes after an initial inquiry by staff with no response from R1.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2023
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 27-AS-20220913143824
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/06/2023
NARRATIVE
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R1 was found by facility staff to be having an alleged seizure and a large piece of food was removed by facility staff during a finger sweep of R1’s mouth. R1 was transported to a local hospital where R1 later passed away. A review of coroner’s report and death certificate revealed R1’s cause of death was anoxic brain injury due to food bolus obstruction of the upper airway.
Based on interviews and record reviews, the department has determined that facility staff did not provide necessary and timely care and supervision as a safety measure for R1 after R1 entered the bathroom being observed by staff to be coughing with mucus and saliva exiting through R1’s mouth. As a result, this allegation is SUBSTANTIATED.

The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22. An immediate civil penalty in the amount of $500 is assessed in addition to the citation issued. This incident is currently under review and a future civil penalty may apply based on 1548(e)(1) H&S. Failure to correct the deficiencies may also result in civil penalties. An exit interview was conducted with Kimberly Camello and a copy of this report was left with Kimberly. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20220913143824
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/09/2023
Section Cited
CCR
80078(a)
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Responsibility for Providing Care and Supervision. (a).The licensee shall provide care and supervision as necessary to meet the client’s needs. This requirement was not met as evidenced by:
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 Licensee will submit a plan ensuring appropriate supervision based on residents’ specific needs. Plan to be submitted to LPA by POC due date.
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Based on interviews and record reviews, licensee did not ensure necessary and timely care and supervision as a safety measure for R1 which lead to choking and death of R1. This posed an immediate health and safety risk to resident in care.
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Licensee and facility staff will ensure completed training by outside certified vendor on the topic of care and supervision and incidental medical care. Training date to be submitted to LPA by POC due date with training to be completed no later than 2 weeks from date of citation issuance. Proof of training to be submitted to LPA prior to citation clearance.
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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: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3