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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700197
Report Date: 11/05/2021
Date Signed: 11/05/2021 03:56:17 PM

Document Has Been Signed on 11/05/2021 03:56 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:CAMELOT CARE BUCKS HARBORFACILITY NUMBER:
342700197
ADMINISTRATOR:CANTILLER, ARACELIFACILITY TYPE:
740
ADDRESS:8006 BUCKS HARBOR WAYTELEPHONE:
(916) 803-0815
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY: 6CENSUS: 5DATE:
11/05/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Staff Ludvina PascualTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Anthony Tuck arrived to conduct an unannounced annual/random inspection on 11/05/2021. LPA met with staff Ludvina Pascual and explained the purpose of the visit. Araceli Cantiller is the Administrator and holds certificate #6043428740 that expires on 01/25/2023.

This facility is a single story building licensed to serve six (6) non-ambulatory residents and has a hospice waiver for 2 residents. LPA toured the physical plant including but not limited to two resident bedrooms, two resident bathrooms, garage and backyard area. LPA observed the facility to be free of odor, clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. There are no bodies of water present.

LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at (112.5) degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Fire extinguishers and smoke and carbon monoxide detectors are in compliance with fire safety. Fire extinguisher last serviced 07/14/2021. Thermostat observed at (73) degrees Fahrenheit. LPA observed centrally stored medications, toxins and sharp knives kept locked and inaccessible to clients. LPA reviewed staff associations to the facility. First aid kit was checked and is complete.

The following forms need updating and were received during today's visit 11/05/2021:
LIC 308, LIC 500, LIC 610, LIC 9020, Administrator certificate, certificate of liability insurance.

No deficiencies were found during today's visit. Exit interview held with Staff Maria Godoy and a copy of report given at the conclusion of the visit.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Anthony Tuck
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2021
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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