397202956-8-10-2022-27-AS-RWAE-CH6NRE-20220810104126

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 397202956
Report Date: 08/10/2022
Date Signed: 08/10/2022 10:41:32 AM

Document Has Been Signed on 08/10/2022 10:41 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		FACILITY NUMBER:	397202956
ADMINISTRATOR:	CAMELLO, KIMBERLY B.		FACILITY TYPE:	735
ADDRESS:	2122 SHADY FOREST WAY		TELEPHONE:	(209) 467-3584
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95205
CAPACITY: 5		CENSUS: 4	DATE:	08/10/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Kimberly Camello - Administrator		TIME COMPLETED:	11:15 AM

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	Licensing Program Analysts (LPA's) Ruth Wallace and Kesha Lewis arrived at this facility unannounced to conduct a Required 1 Year Annual Inspection Visit. LPA's were met by Administrator and screened upon entry for COVID precautions. LPA's explained the purpose of the visit to Administrator. Administrator's Certificate # 60061077735 Expires 7/19/2023 LPA's and Administrator inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry area, living area and other common areas, as well as outside of the facility to ensure compliance with Title 22 regulations. Facility is a 4 bed facility with a current census of 4. There is entry door is leading to the living room, kitchen with a hallway to the bedrooms and bathrooms. The hallway has COVID precautions in place including social distancing noted. Chemicals and medications noted to be locked to residents in care. LPA's also conducted the infection control domain tool. Hot water temperature was measured at 110.7 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees Fahrenheit. All necessary documents were in place. LPA's observed the following posted on the facility wall: Facility license, sketch, See Something Say Something poster, Ombudsman poster, Theft and Loss Policy, Resident Bill of Rights, Rights of Resident/Family Councils. The facility submitted a LIC 808 mitigation plan, which was approved. The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors. LPA's observed the facility to have hand washing stations, COVID - 19 informational signage, and social distancing signs posted throughout the facility, on the front door, and outside. The facility has a designated infection control lead individual. The facility is able to designate and dedicated a COVID -19 room/bathroom if needed. Common touch surfaces are cleaned after each use. LPA's observed the facility to have adequate food supply of 7 days non-perishables and 2 days perishables in place. Resident rooms were sanitary and had the required furniture and furnishings. Continued on 809-C

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022

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	FACILITY NUMBER: 397202956
	VISIT DATE: 08/10/2022

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Continued from 809 - Page 2

The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguishers are current and last inspected on 7/10/2022 . The facility also has a built in alarm system. Facility has an emergency food and water supply in a separate storage area in kitchen. LPA Wallace received the following updated documents: LIC 308 - Designation of Administrator and LIC 601D - Emergency Disaster Plan.

LPA's reviewed four (4) staff files. All staff is fingerprint cleared and associated to the facility and staff have current First Aid or CPR certifications on file. Facility is conducting initial and continuing training as required. LPA's reviewed two (2) resident facility files, COVID-19 Plan, and survey binder.

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held and a report was left at conclusion of visit.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022

LIC809 (FAS) - (06/04)

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