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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 371881438
Report Date: 10/11/2024
Date Signed: 10/11/2024 01:58:04 PM

Document Has Been Signed on 10/11/2024 01:58 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:KAMERON PLACEFACILITY NUMBER:
371881438
ADMINISTRATOR/
DIRECTOR:
REMOT, DHANA C.FACILITY TYPE:
740
ADDRESS:794 MARSOPA DRIVETELEPHONE:
(727) 687-9431
CITY:VISTASTATE: CAZIP CODE:
92081
CAPACITY: 6CENSUS: 3DATE:
10/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:25 PM
MET WITH:Dominador Dacanay - CaregiverTIME VISIT/
INSPECTION COMPLETED:
02:10 PM
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Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced annual required visit. LPA was granted entry and met with caregiver Dominador Dacanay who was informed of the purpose for the visit. At the time of the visit there was two (2) staff and three (3) residents present. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following:

Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. LPA observed outdoor furniture and shaded area for clients. Detergents, cleaning solutions, and sharp and dangerous objects were observed to be locked and inaccessible to residents. The smoke detector and carbon monoxide was operational, and the hot water temperature met department requirements. Facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.



LPA reviewed staff files and training. Staff files have the required personnel records on file and criminal record clearance and training. Three (3) resident files were reviewed. The listed administrator possesses a current administrator's certificate that expires in 05/11/2025. Resident medication was centrally stored and locked in a medication cabinet located in the kitchen. LPA reviewed medications prescribed to residents and found no discrepancies with from the centrally stored medication list. LPA reviewed the facility's emergency and disaster plan and infection control plan. Facility conducts quarterly fire drills with the last fire drill being conducted in 09/10/2024. All facility exits were clear from obstructions. LPA observed emergency supplies, a charged fire extinguishers, and first aid kit with all required items. No deficiencies were cited at the time of the visit.

An exit interview was conducted where a copy of this report was provided to caregiver Dacanay.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2024
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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