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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397202956
Report Date: 05/10/2023
Date Signed: 05/10/2023 12:38:56 PM

Document Has Been Signed on 05/10/2023 12:38 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
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: 3DATE:
05/10/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Pamela AlonzoTIME COMPLETED:
12:00 PM
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On 5/10/23 Licensing Program Analyst (LPA) Kesha Lewis conducted an unannounced case management inspection to follow up on an AWOL incident, which occurred on multiple days 4/17/2023 4/23/2023, .

On multiple days Resident 1 (R1) AWOL'd from the facility through their bedroom window , after previously AWOL'ing on 04/10/2023. The facility was trying to put measures in place to prevent R1 from AWOL'ing including behavior modification and rapid response through VMRC. LPA observed all door and windows to have alarms that are working properly. R1 left the facility on 04/24/2023 and in no longer residing there.

R1'S 602 is incomplete.

LPA took copies of R1'S 602, needs and services, and VMRC placement agreement.

Per California Code of Regulations, Title 22 deficiencies cited during today's inspection see the 809D page.

An exit interview was conducted, and a copy of this report was left at the facility.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2023
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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Document Has Been Signed on 05/10/2023 12:38 PM - It Cannot Be Edited


Created By: Kesha Lewis On 05/10/2023 at 10:49 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: CAMELLO HOME
FACILITY NUMBER: 397202956

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/11/2023
Section Cited
CCR
80078(a)

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80078(a) Responsibility for providing care and supervision. The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement is not met by evidenced by:
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Resident is no longer at the facility. Facility has alarms on all doors and windows.
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Based on records review and SIR'S sent to the department. In April of 2023 R1 left the facility at least 7 times in a 1 month period. Which poses a imitate health and safety risk.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Kesha Lewis
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2023


LIC809 (FAS) - (06/04)
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