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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191221067
Report Date: 04/07/2023
Date Signed: 04/07/2023 11:05:01 AM

Document Has Been Signed on 04/07/2023 11:05 AM - 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
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: 6DATE:
04/07/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
07:45 AM
MET WITH:Estephania RomeroTIME COMPLETED:
08:30 AM
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On 4/07/2023 at 7:45 am, Licensing Program Analyst (LPA) Melissa Spaeth arrived at the facility to conduct an unannounced case management visit and was greeted by the caregiver. . The purpose of this visit is to determine if the deficiency cited on the previous case management visit that took place on 4/05/2023 by LPA Spaeth was completed. ..

During LPA's 4/05/2023 case management visit, LPA stated the licensee will need to complete 20 hours of vendorized training. On April 5, 2023, LPA Spaeth received a call from LIcensee's daughter in law at 11:00 am who stated the Licensee was out of town and would not be able to complete the training requirements by April 6, 2023. Therefore, proof of correction was not provided to LPA by the POC date of 4/06/2023.

Exit interview discussed, appeal rights were given to the caregiver and a copy of the signed report was given to caregiver.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/06/2023
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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