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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000635
Report Date: 10/26/2021
Date Signed: 10/26/2021 04:03:53 PM

Document Has Been Signed on 10/26/2021 04:03 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:CAMEO HOMES - MARINERSFACILITY NUMBER:
306000635
ADMINISTRATOR:ROSE MANABAT PALMAFACILITY TYPE:
740
ADDRESS:1411 MARINERS DRIVETELEPHONE:
(949) 515-8645
CITY:NEWPORT BEACHSTATE: CAZIP CODE:
92660
CAPACITY: 6CENSUS: 5DATE:
10/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Willie Leonardo and Rose PalmaTIME COMPLETED:
11:15 AM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Caregiver Willie Leonardo and explained the reason for the visit. Administrator Rose Palma has an administrator certificate expiring on 11/18/2022. Administrator Rose Palma arrived during the visit.
At 9:12 AM, LPA toured the facility with Caregiver Leonardo. Facility has 5 residents present during today's visit. LPA observed residents relaxing in the facility. All residents appeared happy and well taken care of. Facility appears clean and sanitary. All resident rooms are currently single occupancy and had the required elements as well as restrooms stocked with soap/ sanitizer. Facility screens all visitors to the facility and LPA observed the screening/ sanitizing station in the entrance of the facility. Facility utilizes a visitor sign in sheet and documents temperatures and potential health symptoms. Facility has covid precaution postings as well as most required department postings. First aid kits have all required items. Facility mitigation plan has been submitted and approved. Auditory exit alarms in the master bedroom is inoperable and exit alarm in living room is turned off. Per physician reports, four out of five residents are diagnosed with Dementia with one resident having wandering tendencies. LPA toured the outside grounds and observed multiple shaded outside visitation areas as well as a fenced and secured pool. Exit gates are unlocked and self latching. At 9:25 AM, LPA observed unsecured medication and vitamins in the unlocked caregiver room. LPA toured the kitchen at 9:40 AM and observed unsecured cleaning supplies as well as unsecured scissors in the kitchen area. Facility has ample food supply. Residents participate in activities such as music and bingo. Facility has ample supply of PPE and cleaning supplies. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation and quarantine. LPA reviewed all resident files during the visit and all files are up to date including emergency information and physician reports.
LPA consulted with Administrator Palma regarding the importance of maintaining an ample supply of N95 masks on-site at all times.
Based on the observations made during today's visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 10/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/26/2021
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 10/26/2021 04:03 PM - It Cannot Be Edited


Created By: Kimberly Lyman On 10/26/2021 at 10:16 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CAMEO HOMES - MARINERS
FACILITY NUMBER: 306000635

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/26/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)

The following shall be stored inacessible to residents with Dementia:
Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed unsecured medications, vitamins, scissors, and cleaning supplies. Four out of five residents in the facility are diagnosed with Dementia. This poses an immediate health and safety risk to persons in care.
POC Due Date: 10/27/2021
Plan of Correction
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Licensee to secure noted items and forward proof to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Alisa Ortiz
LICENSING EVALUATOR NAME:Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/26/2021 04:03 PM - It Cannot Be Edited


Created By: Kimberly Lyman On 10/26/2021 at 10:21 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CAMEO HOMES - MARINERS
FACILITY NUMBER: 306000635

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/26/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(j)
The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed the auditory exit alarm in the master bedroom is inoperable and the exit alarm in the living room is turned off. Resident 3 is diagnosed with Dementia and has a wandering risk per physician report. This poses a potential health and safety risk to persons in care.
POC Due Date: 10/12/2021
Plan of Correction
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Licensee corrected the master bedroomexit alarm and will correct the living room alarm and forward proof to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Alisa Ortiz
LICENSING EVALUATOR NAME:Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2021


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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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: CAMEO HOMES - MARINERS
FACILITY NUMBER: 306000635
VISIT DATE: 10/26/2021
NARRATIVE
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This report was discussed with the facility representative and a copy was provided as well as appeal rights.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021
LIC809 (FAS) - (06/04)
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