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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700197
Report Date: 11/16/2023
Date Signed: 11/16/2023 01:05:39 PM

Document Has Been Signed on 11/16/2023 01:05 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) 659-5491
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY: 6CENSUS: 6DATE:
11/16/2023
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Araceli Cantiller - AdministratorTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced required annual inspection visit. LPA met with administrator and explained the purpose of the visit. Administrator certificate #6043428740 expires on 01/25/2023.

This facility is a single story building licensed to serve six non-ambulatory residents and has a hospice waiver for two residents. LPA and staff 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 112.8 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 7/6/2023. Thermostat observed at 75 degrees Fahrenheit. LPA observed centrally stored medications, toxins and sharp knives kept locked and inaccessible to residents.

LPA reviewed three resident files and three staff files. A review of staff records indicates that all facility staff & other individuals who require caregiver background checks are fingerprint cleared and to the facility. LPA verified staff training for staff file reviews and all three staff have current First Aid Certificates.

LPA requested the following updated documents to be submitted via email to community care licensing by 12/4/2023: LIC 308 - Designation of Administrator, LIC 500 - Personnel Report, copy of administrator's certificate, and liability insurance.
ruth.wallace@dss.ca.gov

Per the California Code of Regulations, Title 22 no deficiencies were observed or cited. 
Exit interview held with administrator. A report and LIC 811 (Confidential Names) was left at the facility.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2023
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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