Camelot Residential Home

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Tena Herrera conducted the required annual inspection. LPA met with Evangeline De Casa (Administrator) and explained the purpose for today’s visit. The facility is licensed to serve 16 ambulatory and 4 non-ambulatory residents ages 60 and above. There is an approved hospice waiver for 1 resident. - This is single-story facility located in Bellflower, Ca. A tour of the facility consists of 2 separate units and independent rooms with private bath along the back/outside. Main unit consists of kitchen, living room, dining areas, 4 resident bedrooms, 1 staff room/storage/medication room, 1 staff office. Leading to the exterior there are 6 private units with private baths. Detached garage and storage rooms/staff break room/backup refrigerator and freezer with food. Separate unit consists of 4 bedrooms and 2 bathrooms. There is a locked laundry area and linen storage near the separate unit. Facility has a large outside activity area, back yard, front yard and parking area in back yard. There is a fire sprinkler system throughout the facility. LPA used the Compliance and Regulatory Enforcement (CARE) tools for the visit todays visit and observed the following: Infection Control: The facility maintains the required Infection Control Plan. Operational Requirements: The facility has an approved fire clearance and maintains valid liability insurance Planned Activities: There is an outdoor activity area available for the residents. Administrator Stated that Staff #5 is the designated staff with the primary responsibility being to plan,prepare and conduct activities, however, after file review S5 does not have the proper training or education. LPA arrived to facility at 10:56am and left at 3:20pm, there were no observations of activities being conducted and S5 was not present at facility, citation being issued and detailed on LIC809-D page. Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. (Continued on LIC809-C) Physical Plant & Environment Safety: LPA toured facility, residents’ bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. The front yard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. The hot water temperature was tested throughout the facility and measured within the required range of 105-120 degrees F. All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept in areas with a lock, however, during tour LPA observed unlocked cleaning supplies/chemicals in main bulidings bathroom and in Resident #2's bathroom within Room #1, citation will be issued. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged. Staffing & Personnel Records-Training: There appears to be sufficient staffing at all times in the facility. Staff has criminal record clearance, current First-Aid/CPR/AED training along with training in postural supports, medication assistance, and other ongoing training are documented in personnel files. LPA reviewed 5 staff files with no issues. Administrator Evangeline De Casa maintains a valid administrator certificate that expires on 11/8/2026. Resident Records-Incident Reports: Resident files are kept in a secure location and have the following documents in their files - Pre-admission appraisal/Appraisal Needs & Services Plan, Admission Agreements, Identification & Emergency Information and current Physician's Report. LPA reviewed 5 Resident Files with no issues. Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility has the following posters posted: Residents Rights, Complaint Poster, and Ombudsman. Incidental Medical & Dental: LPA conducted medication review and observed the following errors: R7 is missing 1 PRN medication; Facility does not have any the required documentation of medication review from nurse/pharmacist; R6 and R7 have 1 medication that is not properly labeled; Facility is prepackaging medication in a separate container for each resident a week prior to administering. citations issued. Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Last Earthquake drill was conducted on 6/13/26. Residents with Special Health Needs: There are no residents using hospice services at this time. - Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit will be documented on the LIC809-D. - Exit interview held, a copy of the report and appeal rights were provided to Evangeline De Casa.the state’s words, verbatim · CDSS document, Jul 16, 2026

Allegation investigated: Staff did not ensure that the resident's room was maintained in a clean and sanitary condition.

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint visit to investigate the allegation listed above. LPA met with Administrator Evangelina and explained the purpose of the visit. The investigation consisted of the following: LPA obtained copies of the Staff and Resident rosters, toured facility, and conducted interviews with 2 Staff and 5 Residents. (Continued on LIC9099-C) Unsubstantiated The investigation revealed the following: Allegation: Staff did not ensure that the resident's room was maintained in a clean and sanitary condition. It is alleged that staff leave residents floor and toilet unclean. LPA toured facility, restrooms and flooring in both main unit with kitchen and neighboring unit did appear to have unclean floors, restrooms in both units were entered and appeared clean and sanitary. LPA toured 4 individual rooms outside of units, each room has a private bath, floors and restroom in each room appeared clean and sanitary. LPA interviewed 2 staff and each denied the allegation and stated that the facility is swept and mopped daily, rooms are cleaned regularly or as needed when a resident mentions cleaning is needed. LPA interviewed 5 Residents and 4 denied the allegation; they stated staff clean regularly and have not observed the floors or restroom being left dirty or unsanitary and don’t find this as a concern. Based on statements and interviews conducted with staff/residents, and LPA’s observations, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 15, 2026 · control 28-AS-20260512160512

Type of visit: Office

An informal conference was held at the Monterey Park Adult and Senior Care Program Regional Office on 3/1/26. The individuals present for the meeting were: Tony Vasallo (Regional Manager), David Sicairos (Licensing Program Manager), Tena Herrera (Licensing Program Analyst), Jefferson Bautista (Facility's Licensee), and Evangeline De Casa (Facility Administrator/Vice President). The purpose of the meeting is to discuss the citations issued for staff failing to seek medical attention in a timely manner and staff neglect resulting in an unstageable pressure injury for complaint control # 28-AS-20190219134922. The department concluded the investigation on 11/13/2019, and the following deficiencies were issued for: 87758(a)(11) Serious Deficiencies and 87615(a)(1) Prohibited Health Conditions, along with an immediate $500 civil penalty. The community care licensing department has determined that an additional civil penalty will be assessed due to neglect resulting in an unstageable pressure injury and not seeking medical attention in a timely manner to a client in care. The additional civil penalty will be delivered at a later date and time. Licensee confirmed during meeting that they have since implemented a more thorough intake/assessment during the admission process to ensure the facility can meet the needs of residents prior to admission. The licensee and administrator have been advised that the department is seeking an additional civil penalty. An exit interview, and a copy of this report was provided to Jefferson Bautista.the state’s words, verbatim · CDSS document, Mar 2, 2026

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Tena Herrera and Gabriela Castro conducted the required annual inspection. LPA met with Evangeline De Casa (Administrator), the purpose for today’s visit was explained. The facility is licensed to serve 16 ambulatory and 4 non-ambulatory residents ages 60 and above. There is an approved hospice waiver for 1 resident. - This is single-story facility located in Bellflower, Ca. A tour of the facility consists of 2 separate units and independent rooms with private bath along the back/outside. Main unit consists of kitchen, living room, dining areas, 4 resident bedrooms, 1 staff room/storage/medication room, 1 staff office. Leading to the exterior there are 6 private units with private baths. Detached garage and storage rooms/staff break room/backup refrigerator and freezer with food. Separate unit consists of 4 bedrooms and 2 bathrooms. There is a locked laundry area and linen storage near the separate unit. Facility has a large outside activity area, back yard, front yard and parking area in back yard. There is a fire sprinkler system throughout the facility. - LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit todays visit and the initial visit and observed the following: Infection Control: The facility maintains the required Infection Control Plan. Operational Requirements: The facility has an approved fire clearance. facility maintains liability insurance. Physical Plant & Environment Safety: LPA toured facility, residents’ bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. The front yard is free of debris/hazards and the outdoor and passageways are free of obstruction. (Continued on LIC809-C) (Continued) No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. The hot water temperature was tested throughout the facility and measured within the required range of 105-120 degrees F. All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept in a locked and are inaccessible to residents. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged. Last fire/disaster/earthquake drill was conducted on 7/3/24. Staffing & Personnel Records-Training: There appears to be sufficient staffing at all times in the facility. Staff has criminal record clearance, current First-Aid/CPR/AED training along with training in postural supports, medication assistance, and other ongoing training are documented in personnel files. LPA reviewed 5 staff files, Administrator Evangeline De Casa maintains a valid administrator certificate that expires on 11/8/2026. Resident Records-Incident Reports: Resident files are kept in a secure location and have the following documents in their files - Pre-admission appraisal/Appraisal Needs & Services Plan, Admission Agreements, Identification & Emergency Information and current Physician's Report. LPA reviewed 7 Resident Files and noticed residents 1-4 and 7 are missing their current appraisal, and resident # 7 was missing their signed admission agreement, deficiencies will be documented on LIC809-D. Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility has the following posters posted: Residents Rights, Complaint Poster, and Ombudsman. Planned Activities: Facility provides scheduled activities and have a variety of activities to choose from. There is an outdoor activity area available for the residents. Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. Incidental Medical & Dental: Medication is properly labeled and are centrally stored in locked cabinet, medication was observed to be in their original containers. Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Residents with Special Health Needs: There are no using hospice services, nor bedridden or residents with postural supports at this time. - Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit will be documented on the LIC809-D. - Exit interview held, a copy of the report and appeal rights were emailed to Evangeline De Casa.the state’s words, verbatim · CDSS document, Aug 15, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and was greeted by Rudolfo Macaliano (Caregiver) who allowed entrance to the facility, shortly after Evangeline De Casa (Administrator) arrived to assist with the visit, the purpose for today’s visit was explained. The facility is licensed to serve 16 ambulatory and 4 non-ambulatory residents ages 60 and above. There is an approved hospice waiver for 1 resident. The facility currently has 16 residents. - The facility is a single-story home located in Bellflower, Ca. A tour of the facility consists of 2 separate units and independent rooms with private bath along the back/outside. Main unit consists of kitchen, living room, dining areas, 4 resident bedrooms, 1 staff room/storage/medication room, 1 staff office. Leading to the exterior there are 6 private units with private baths. Detached garage and storage rooms/staff break room/backup refrigerator and freezer with food. Separate unit consists of 4 bedrooms and 2 bathrooms. There is a locked laundry area and linen storage near the separate unit. Facility has a large outside activity area, back yard, front yard and parking area in back yard. There is a fire sprinkler system throughout the facility. - LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit todays visit and the initial visit and observed the following: Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting residents’ medications. Staff are cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan maintained at the facility. Operational Requirements: The facility has an approved fire clearance, there is a plan of operation with required Infection Control Plan and facility maintains liability insurance, however, the amount covered on aggregate was not the amount that facility is required to maintain (citation issued and will be documented on 809D). Fire Marshal arrived during visit and conducted an annual inspection with no issues. Physical Plant & Environment Safety: LPA toured facility, residents’ bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. The front yard is free of debris/hazards and the outdoor and passageways are free of obstruction. (Continued on LIC809-C) (Continued) No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. The hot water temperature was tested throughout the facility and measured within the required range of 105-120 degrees F. All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept in a locked and are inaccessible to residents. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged. Last fire/disaster/earthquake drill was conducted on 7/3/24. Staffing: There appears to be sufficient staffing at all times in the facility. With night staff that is trained and able to assist in care and supervision of the residents in the case of an emergency. Personnel Records-Training: Staff has criminal record clearance, current First-Aid/CPR/AED training along with training in postural supports, medication assistance, and other ongoing training are documented in personnel files. LPA reviewed 4 staff files, Staff #3 and Staff #2 were missing training in Alzheimer’s and Dementia (citation will be issued and documented on 809D). Administrator Evangeline De Casa maintains a valid administrator certificate that expires on 11/8/2024. Resident Records-Incident Reports: Resident files are kept in a secure location (within staff office) and have the following documents in their files - Pre-admission appraisal/Appraisal Needs & Services Plan, Admission Agreements, Identification & Emergency Information and current Physician's Report. LPA reviewed 4 Resident Files with no issues observed. Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility has the following posters posted: Residents Rights, Complaint Poster, and Ombudsman. Planned Activities: Facility provides scheduled activities and have a variety of activities to choose from within the facility. There is an outdoor activity area available for the residents. Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. Incidental Medical & Dental: Medication is properly labeled and are centrally stored in locked staff room and locked cabinet, medication was observed to be in their original containers. Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Residents with Special Health Needs: There are no bedridden or residents with postural supports at this facility. - Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit will be documented on the LIC809-D. - Exit interview held, a copy of the report, appeal rights and list of confidential names to identify staff, were provided to Evangeline De Casa.the state’s words, verbatim · CDSS document, Jul 18, 2024