397004738-10-24-2023-27-AS-MBIR-CWWUKN-20231024153927

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 397004738
Report Date: 10/24/2023
Date Signed: 10/24/2023 03:39:32 PM

Document Has Been Signed on 10/24/2023 03:39 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 1		FACILITY NUMBER:	397004738
ADMINISTRATOR:	CAMELLO, KIMBERLY		FACILITY TYPE:	735
ADDRESS:	2203 MICHIGAN AVENUE		TELEPHONE:	(209) 598-2036
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95204
CAPACITY: 5		CENSUS: 1	DATE:	10/24/2023
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Kimberly Camello		TIME COMPLETED:	03:50 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 10-24-23 at 1:30pm, Licensing Program Analysts (LPAs) Michael Bilger and Arvin Villanueva conducted an unannounced complaint investigation to follow up on a substantiated allegation of lack of care and supervision which led to the death of a resident for a complaint that was received on 9-13-22. LPAs met with the Licensee Kimberly Camello, and explained the reason for the visit. Based on the investigation, the allegation was substantiated, and the licensee was cited for a violation of California Code of Regulations (CCR) Title 22, Division 6 section 80078(a) Responsibility of Providing Care and Supervision and CCR Title 22, Division 6, section 85064(j)(4) Administrator Qualifications and Duties for not ensuring a provision of safety and supervision. The investigation revealed that on February 14, 2021, a resident (R1) was served a tri-tip steak sandwich for lunch. During this meal period, staff (S2) observed R1 to be coughing with clear mucus and saliva coming out of R1’s mouth and nose. R1 covered their mouth with a napkin and ran to the bathroom and closed the door. S2 knocked on the door but did not hear anything and observed the door to be locked. An estimated time of five (5) minutes lapsed from when R1 entered the bathroom and S2 knocking on the bathroom door. {Cont. on 809C}

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023

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: 10/24/2023

NARRATIVE

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S2 was instructed by the licensee to take other residents on an outing. An estimated time of eight (8) to nine (9) minutes lapsed from when R1 was coughing at the table and S2 left the facility, with R1 remaining in the bathroom at this time. After S2 left with the other residents, another staff (S1) heard a “thump” and proceeded to open the door. Upon S1 opening the door, S1 observed R1 to be having an alleged seizure, called 911, and performed a finger sweep of R1’s mouth. A large piece of tri-tip was removed by S1 and S1 performed chest compressions on R1. R1 was transported to the local hospital where R1 passed away the same day.

In April 2019, R1’s IPP indicated and R1’s doctor ordered that R1 follow a Dysphagia II diet. R1 had a delay in R1’s swallow due to R1’s food/drink going into a sinus pocket before going down and needed food chopped. According to medical records obtained from local acute hospital, R1 suffered from and was diagnosed with cardiopulmonary arrest with notation of a contributing factor stating, “patient was choking on steak at home.” According to an emergency response care report from the emergency medical transport company arriving to the scene on February 14, 2021, primary impression was noted as “respiratory airway obstruction/choking with secondary impression noted as arrest/shock – cardiac arrest.” According to the coroner’s report, obtained on September 23, 2022, from a local county office of the medical examiner, and death certificate for R1 obtained on September 27, 2022, immediate cause of death was noted as anoxic brain injury due to food bolus obstruction of the upper airway.

Based on interviews, record reviews, and observation, the licensee did not ensure food served to R1 was appropriately sized for R1’s doctor ordered diet, and that the licensee delayed checking on the resident after the choking incident. {Cont. on 809C}

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023

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: 10/24/2023

NARRATIVE

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At the time of the complaint visit, the issuance of a civil penalty was still being determined and the licensee was informed that a civil penalty might be assessed based on Health and Safety Code section 1548(e)(1) which states: “for a violation that the Department determines resulted in the death of a resident at an adult residential facility, …, the civil penalty shall be fifteen thousand dollars ($15,000).”

The Department has concluded an analysis and determined that a civil penalty is warranted for a violation of CCR Title 22, Division 6, section 80078(a), failure to provide the care and necessary supervision warranted to prevent the resident from choking which resulted in death.

Today October 24^th, 2023 the Department will be issuing a civil penalty per Health and Safety Code section 1548(e)(1) for a violation that the Department determines resulted in the death of a resident in the amount of fifteen thousand dollars ($15,000). However, since an immediate civil penalty of five hundred dollars ($500) was previously issued on January 06, 2023, the amount of the civil penalty issued today will be fourteen thousand five hundred dollars ($14,500).

A copy of the LIC 421D was given to Kimberly Camello and originals were signed.

Exit interview conducted. A copy of the report issued. Appeal Rights provided. Kimberly Camello’s signature on this report acknowledges receipt of the Appeal Rights, found on page two of LIC 421D.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023

LIC809 (FAS) - (06/04)

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