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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191221067
Report Date: 08/04/2022
Date Signed: 08/04/2022 03:44:12 PM

Substantiated


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
07/06/2022 and conducted by Evaluator Shira Stamps
COMPLAINT CONTROL NUMBER: 31-AS-20220706140941
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: 5DATE:
08/04/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Felix Campos, LicenseeTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Lack of care and supervision.
INVESTIGATION FINDINGS:
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At 10:30am, Licensing Program Analysts (LPAs) Shira Stamps and Melissa Ruiz conducted a subsequent complaint visit to investigate the above allegations. Upon arrival the entry gate was closed, and LPAs were unable to ring the doorbell due to a dog on the facility premises. LPAs called the Licensee and left a message. LPAs waited over thirty (30) minutes for a call back.When LPAs did not receive a call back, LPAs left the facility to conduct another visit at Westside Care Home. Since Felix was present at the facility, LPAs delivered the complaint report to the Licensee. Entrance interview conducted.

Allegation: Lack of Care and Supervision
It is alleged that there are no caregivers in the home, and clients are staying in the home without supervision. Staff interviews indicated clients are left at the facility with no staff members from time to time. Therefore, based on interviews the allegation, “Lack of care and supervision,” is deemed substantiated. Licensee refused to sign due to him leaving the facility to take clients to the doctor.
Exit interview conducted, citations and civil penalties issued, appeal rights and copy of report left for Licensee.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022
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 4
Control Number 31-AS-20220706140941
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/05/2022
Section Cited
CCR
85065(b)
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Personnel Requirements (b) The licensee shall employ staff as necessary to ensure provision of care and supervision to meet client needs.

This requirement is not met as evidenced by:
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Licensee has stated that they are in the process of hiring additional staff. Licensee will provide proof of fingerprint clearance for new staff and an updated LIC500 by the POC due date.
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Based on observation and interviews, the licensee failed to ensure that sufficient staff were present at all times and left the clients unsupervised which poses an immediate health, safety, or personal rights risk to clients in care. This is a zero-tolerance issue, and a civil penalty will be issued.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
07/06/2022 and conducted by Evaluator Shira Stamps
COMPLAINT CONTROL NUMBER: 31-AS-20220706140941

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:
08/04/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Felix Campos, LicenseeTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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2
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5
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9
Clients are distributing medications to other clients.

The facility is not providing basic services to clients
INVESTIGATION FINDINGS:
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3
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5
6
7
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9
10
11
12
13
At 10:30am, Licensing Program Analysts (LPAs) Shira Stamps and Melissa Ruiz conducted a subsequent complaint visit to investigate the above allegations. Upon arrival the entry gate was closed, and LPAs were unable to ring the doorbell due to a dog on the facility premises. LPAs called the Licensee and left a message. LPAs waited over thirty (30) minutes for a call back.When LPAs did not receive a call back, LPAs left the facility to conduct another visit at Westside Care Home. Since Felix was present at the facility, LPAs delivered the complaint report to the Licensee. Entrance interview conducted.

Allegation: Clients are distributing medications to other clients.
It is alleged that clients are distributing medications to other clients when the caregiver is not in the home. Interviews with five (5) out of five (5) clients indicated clients do not give other clients medications. Staff interviews also indicated medications are not given by clients, and that one (1) client manages their own medications. Therefore, based on interviews the allegation, “Clients are distributing medications to other clients,” is deemed unsubstantiated. CONTINUED..
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 31-AS-20220706140941
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: 08/04/2022
NARRATIVE
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Staff interviews also indicated medications are not given by clients, and that one (1) client manages their own medications. Therefore, based on interviews the allegation, “Clients are distributing medications to other clients,” is deemed unsubstantiated.

Allegation: The facility is not providing basic services to clients

It is alleged that the caregiver is giving clients’ money to do the grocery shopping for the home. It is also alleged that clients will cook meals for the entire home, and the Licensee will pay the clients for their assistance. Interviews with clients indicated staff cook all meals and do the grocery shopping for the home. Staff interviews also indicated that staff cook all meals and do the grocery shopping for the home. Therefore, based on interviews the allegation, “The facility is not providing basic services to clients,” is deemed unsubstantiated. Licensee refused to sign due to him leaving the facility to take clients to the doctor.

Exit interview conducted, appeal rights and copy of report left for Licensee.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4