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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004738
Report Date: 01/31/2023
Date Signed: 01/31/2023 11:46:40 AM

Document Has Been Signed on 01/31/2023 11:46 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
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:
01/31/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:34 AM
MET WITH:Kimberly CamelloTIME COMPLETED:
12:00 PM
NARRATIVE
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On 1-31-23 at 10:34am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit. Case management was conducted in regards to an incident which originally occurred on 2-14-2021 and a recent investigation based on complaint #27-AS-20220913143824. LPA met with Administrator Kimberly Camello and explained the purpose of the visit. LPA reviewed incident report dated 2-14-2021 , information face sheet, and recently completed investigation. Based on interviews and record reviews conducted, it was determined that resident1 (R1) experienced a choking episode on 2-14-21 while eating a meal at the dining table. R1 was observed by staff to be coughing with mucus and saliva exiting R1’s mouth and nose. R1 went to the bathroom and water was heard running. It was further determined that staff member was instructed to take remaining residents on an outing while Administrator remained on duty to supervise R1. A review of information face sheet states, as result of a swallow evaluation on 4-2-2019, R1 has a “delay in her swallow due to her food/drink going into a sinus pocket before going down.” Based on interviews and record reviews, it was determined that Administrator, who is also the Licensee of facility did not adhere to appropriate levels of care and supervision in 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. 911 was notified and R1 was taken to a local hospital where R1 was pronounced deceased.

As a result of this case management, a citation is issued under Title 22, Division 6. 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: 01/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2023
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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Document Has Been Signed on 01/31/2023 11:46 AM - It Cannot Be Edited


Created By: Michael Bilger On 01/31/2023 at 10:56 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: CAMELLO HOME 1
FACILITY NUMBER: 397004738

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/01/2023
Section Cited
CCR
85064(j)(4)

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 Administrator Qualifications and Duties. (j) The administrator shall perform the following duties: (4) Provision of…services to the clients, required by applicable law and regulation, including those services identified in the client's individual needs and services plans. The requirement was not met as evidenced by:
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Licensee will develop a plan of care and supervision to include how Administrator will develop procedures on providing services to residents based on their care needs.
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Based on interviews and record reviews, R1 experience a choking episode and Administrator on duty did not provide an adeqauate service of care and supervision for R1 which led to R1’s hospitalization and eventual death. This posed an immediate health and safety risk to resident 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.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Michael Bilger
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2023


LIC809 (FAS) - (06/04)
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