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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004738
Report Date: 06/28/2023
Date Signed: 06/28/2023 03:38:14 PM

Document Has Been Signed on 06/28/2023 03:38 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
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:
06/28/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Kimberly CamelloTIME COMPLETED:
03:27 PM
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On 6-28-23 at 2:30pm, an office meeting was held to discuss the summary of the Technical Support Program (TSP) visits conducted on 4-4-2023, 4-21-2023, and 5-2-2023. This meeting was held virtually via Teams Meeting. Present at this meeting were Licensing Program Manager (LPM) Liza King, Licensing Program Analyst (LPA) Michael Bilger, Regional Center Representative Rukaiyah Jones, and Licensee Kimberly Camello.

Referral Reason #1 – Care and Supervision

TSP discussed with licensee during the above visit dates plans to ensure adequate care and supervision for clients served. Licensee stated increased supervision and the assurance of administrator coverage at least 40 hours per week. Additionally, training and client care plans have been updated. Licensee also stated a current plan is in place to ensure access to locked doors for purposes of client safety. During these visits, TSP provided training and additional resources to Licensee to help secure compliance.

Referral Reason #2 – Record Keeping

TSP discussed with licensee during the above visit dates the challenges Licensee was experiencing regarding regulatory record keeping as related to the administration of the facility. TSP provided training and resources including needs and service plans and incident reporting.

In addition to above, LPM and LPA discussed with Licensee various challenges regarding needed interventions for clients and the importance of maintaining updated service plans. During today’s meeting, Licensee was also made aware of the following TSP’s recommendations for post-engagement: (1) Completing a facility self-assessment every quarter and record actions taken when identified, (2) Subscribe to CCLD information sharing service, (3) Continue to follow established plans for appropriate levels of supervision and client intervention including, but not limited to “Care and Supervision” as described above, (4) Continue to review and comply with all laws and regulations specific to Adult Residential Facilities (ARF), {Cont. on 809C}

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 06/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/28/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/28/2023
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(5) Continue to utilize Provider Information Notices (PIN) and other resources to aid in compliance, (6) Continue to follow all other additional recommendations from TSP. (7) Continue to ensure an on-duty Administrator present at the facility at least 40 hours per week.

Licensee was made aware that quarterly visit will continue at this time to ensure the compliance with above and overall regulatory compliance. LPM and LPAs notified Administrator that future non-compliance regarding the above and other regulatory components will result in additional citations, civil penalties, and a non-compliance conference to discuss further potential administrative action.

No citations issued as a result of today’s visit. An exit interview was conducted with Licensee Kimberly Camello and a copy of this report was emailed to Licensee with a request to return with signature.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2023
LIC809 (FAS) - (06/04)
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