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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004738
Report Date: 05/04/2023
Date Signed: 05/04/2023 11:51:52 AM

Document Has Been Signed on 05/04/2023 11:51 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:
05/04/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:27 AM
MET WITH:Kimberly CamelloTIME COMPLETED:
12:00 PM
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On 5-4-23 at 10:27am, Licensing Program Analyst,( LPA) Michael Bilger arrived at this facility unannounced to conduct a quarterly health and safety visit. LPA met with the administrator Kimberly Camello and explained the purpose of the visit.

LPA Bilger inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside backyard of the facility to ensure compliance with Title 22 regulations. Facility is a 5 bed adult residential facility with a current census of 3.

Water temperature reads between 105*F to 120*F in the bathroom and room temperature reads 73*F. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Facility has an emergency food and water kit.

LPA reviewed 3 resident files and noted all physician orders to match dietary needs at this time as well as other prescribed medication. All resident care plans are updated accordingly. LPA also reviewed 5 staff files which contained necessary staff training on care and supervision procedures, timely medical attention, following dietary orders. LPA observed written plan for ensuring availability of keys for all staff on duty in the event of emergencies. Dietary needs and precaution training was reviewed by LPA and observed to be completed on 01/27/2023..

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held and a report was given to Administrator Kimberly Camello.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/04/2023
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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