<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001914
Report Date: 12/26/2024
Date Signed: 03/25/2025 11:59:37 AM

Document Has Been Signed on 03/25/2025 11:59 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:CAMEO HOMES - EASTSIDE IFACILITY NUMBER:
306001914
ADMINISTRATOR/
DIRECTOR:		LISE BRICKFACILITY TYPE:
740
ADDRESS:236 EAST 20TH STREETTELEPHONE:
(949) 939-3935
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY: 6CENSUS: 5DATE:
12/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Lise BrickTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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
On December 26, 2024, at 8:00am, Licensing Program Analyst (LPA) Eboni Bentley conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Bentley was greeted and granted entry by House Manager/Administrator (AD) Dennis Macatangay. Administrator (AD) Rose Palma (formerly Rose Jovan) arrived at the facility around 8:30am, and later Licensee Lise Brick.

The facility is licensed to operate for six (6) non-ambulatory residents and has a hospice waiver for six (6) residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: five (5) resident bedrooms, (1) staff bedroom, two (2) bathrooms, living room area, dining area, kitchen, an outdoor covered seating area, and an attached two car garage.

Around 9:30am, LPA Bentley toured the inside and outside of the physical plant with AD Palma. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for each resident’s personal belongings was observed. Five (5) residents were present at the time of visit. The Resident’s rooms were inspected: Resident Room 1, Resident Room 2, Resident Room 3, Resident Room 4, and Resident Room 5. Bathrooms were found to be clean and operational. The water temperature measured at 115.4 degrees F to 119.0 degrees F. A comfortable temperature of 72 degrees F was maintained in the facility.

LPA Bentley observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. Emergency safety drills were last conducted on September 16, 2024 and conducted quarterly. First aid kit is maintained and contains all the necessary elements.
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: CAMEO HOMES - EASTSIDE I
FACILITY NUMBER: 306001914
VISIT DATE: 12/26/2024
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
26
27
28
29
30
31
32
During the visit, LPA Bentley observed the facility's infection control practices, plan of operation, and visitors policy. The smoke detectors and carbon monoxide detectors were operable. A working telephone (949-650-4908) remains available, and the facility has a device that can be used for video teleconference purposes. Emergency food, emergency water, and emergency supplies were stored in the garage. The facility has two (2) fire extinguishers that were charged, mounted in the kitchen and hallway, and serviced on February 8, 2024. Liability Insurance is effective March 5, 2024 and expires on March 5, 2025.

LPA Bentley conducted an audit of five (5) resident files (R1-R5), three (3) staff files (S1-S3), and medication and medication administration review were all in order and complete. LPA Bentley conducted two (2) staff interviews and four (4) resident interviews.

Based on observations made during today’s inspection, no deficiencies were cited during the time of the visit per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and a copy of this report was provided to Administrator Rose Palma.

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2