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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191221067
Report Date: 12/28/2021
Date Signed: 12/28/2021 02:33:18 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/22/2021 and conducted by Evaluator Shira Stamps
COMPLAINT CONTROL NUMBER: 31-AS-20211222105809
FACILITY NAME:CAMPOS CARE HOMEFACILITY NUMBER:
191221067
ADMINISTRATOR:CECILIA T. CAMPOSFACILITY TYPE:
735
ADDRESS:226 E. AVENUE Q-3TELEPHONE:
(661) 274-9509
CITY:PALMDALESTATE: CAZIP CODE:
93550
CAPACITY:6CENSUS: DATE:
12/28/2021
UNANNOUNCEDTIME BEGAN:
01:18 PM
MET WITH:TIME COMPLETED:
02:40 PM
ALLEGATION(S):
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Resident was hit by staff while in care.

Facility did not return residents personal belongings.
INVESTIGATION FINDINGS:
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At 1:18pm Licensing Program Analyst (LPA) Shira Stamps arrived at the facility mentioned above for a complaint visit. Entrance interview conducted.

At approximately 1:20 pm, LPA conducted a physical plant walk through, and LPA did not observe any immediate health and safety issues during this visit. LPA began interviewing residents and staff members from 1:20pm-2:15pm.

Allegation: Resident was hit by staff while in care.

Interviews with Five (5) out of six (6) residents indicated they have never seen a staff member hit a resident. One (1) out of six (6) residents were unable to be interviewed, since they were out in the community. Interviews with three (3) out of three (3) staff members indicated a staff member has never hit a resident. Based upon interviews the allegation, “Resident was hit by staff while in care.,” is deemed unsubstantiated.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 31-AS-20211222105809
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: CAMPOS CARE HOME
FACILITY NUMBER: 191221067
VISIT DATE: 12/28/2021
NARRATIVE
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Allegation: Facility did not return residents personal belongings.

Interviews with two (2) out of three (3) staff members indicated that personal belongings are returned to residents when they relocate. One (1) out of thee (3) staff members did not know the facility procedure for returning belongings to residents. LPA reviewed documentation showing personal belongings are returned to residents. Therefore, after review of the information and interviews conducted the allegation, “Facility did not return residents personal belongings,” is deemed unsubstantiated.

Exit interview conducted. Report delivered.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2