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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397202956
Report Date: 04/10/2023
Date Signed: 04/11/2023 04:30:19 PM

Document Has Been Signed on 04/11/2023 04:30 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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:CAMELLO HOMEFACILITY NUMBER:
397202956
ADMINISTRATOR:CAMELLO, KIMBERLY B.FACILITY TYPE:
735
ADDRESS:2122 SHADY FOREST WAYTELEPHONE:
(209) 467-3584
CITY:STOCKTONSTATE: CAZIP CODE:
95205
CAPACITY: 5CENSUS: 4DATE:
04/10/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Pamela AlonzoTIME COMPLETED:
03:15 PM
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LPA Lewis arrived unannounced at the facility and met administrator to conduct a case management visit regarding incidents that took place on 03/29-31/2023, 04/01-04/2023, 04/04/2023 and 04/07/2023.


R1 is refusing to take their medication on multiple occasions and is AWOL'S on multiple occasions.

LPA conducted a case management inspection to ensure Title 22 compliance and health and safety concerns. An interview was conducted with the administrator and the facility was toured .LPA Lewis also reviewed resident records to check for completeness, all necessary documents were in place.


Based on inspection, and documentation reviewed during this case management, the department has closed this case management and no further investigation is required. No deficiencies were cited as a result of today’s visit.

An exit interview was conducted and a copy of this report was left.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 04/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/10/2023
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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