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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601463
Report Date: 01/23/2023
Date Signed: 01/23/2023 01:12:33 PM

Document Has Been Signed on 01/23/2023 01:12 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:CAMELOTFACILITY NUMBER:
374601463
ADMINISTRATOR:MOSS, JUDITHFACILITY TYPE:
735
ADDRESS:2035 ALTA VISTA DRIVETELEPHONE:
(760) 724-7898
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY: 6CENSUS: 3DATE:
01/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:ADMINISTRATOR, JUDITH MOSS.TIME COMPLETED:
01:16 PM
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 On January 23, 2023, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced for the purpose of completing the facility's Annual Inspection. LPA Mixson met with Administrator, Judith introduced self and stated the purpose of the visit, with an emphasis on Infection Control.

Present in the facility were three residents and two staff. Currently there are no positive cases of COVID-19 within the facility.

LPA Mixson observed residents have hand sanitizer available to them, and all restrooms were stocked with liquid soap and paper towels. LPA Mixson observed sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions and the proper use of face coverings.


The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, and cleaning and disinfection provisions are in adequate quantities. LPA Mixson later discussed infection control practices and procedures with Administrator.



An exit interview was conducted and a copy of this report, along with the LIC 811, was provided to Administrator.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 01/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/06/2023
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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