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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191221067
Report Date: 12/28/2021
Date Signed: 12/28/2021 11:26:59 AM

Document Has Been Signed on 12/28/2021 11:26 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:
12/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Cecilia Campos, AdministratorTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Shira Stamps met with Administrator Cecilia and Felix Campos for an unannounced one (1) year Required visit for this facility.

LPA arrived at 9:45am and was greeted by caregiver Michael Villanueva. One (1) resident was observed in the living room watching TV. The rest of the residents were observed to be in their rooms watching TV and/or resting. Administrator Cecilia and Felix Campos arrived at 10:00am. LPA informed the Administrator of the purpose of the visit.

Infection control: LPA reviewed facility mitigation plan (approved on 03/06/21) to make sure licensee was following current infection control recommendations. Upon arrival LPA was screened by the caregiver and asked all infection control questions. LPA was asked to sign-in and sanitize/wash hands.

A tour of the physical plant was conducted with Administrator at 10:01am. The facility has three (3) bedrooms and two (2) bathrooms currently occupying six (6) residents. One (1) bathroom is designated for staff use only or over flow for the residents in an emergency, and the facility has awake staff at night. The facility is Fire Cleared for six (6) ambulatory.

Resident Rooms
LPA observed rooms to have the appropriate bedding. There is a night stand and sufficient lighting for each resident.

Bathrooms
At 10:16am LPA observed all bathrooms to have non-skid matts, and the appropriated wash your hands signs posted. Hot water was tested at 10:16am and measured within regulation at 116.8 degrees F.

Continued....
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.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
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Laundry
LPA observed chemicals/hazardous items in an unlocked cabinet in the laundry room. Chemicals/Hazardous materials was also found in the hallway cabinet.

Food Inspection
LPA conducted a tour of the kitchen around 10:20am observed there to be sufficient stock of two-day perishables and seven-day non-perishables foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are care clean and inaccessible to pests. LPA observed all knives and sharp object locked and inaccessible to residents in care.

Physical environment
LPA toured the outside area of the facility at 10:22am. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. No bodies of water on the premises.

Living and dining
LPA observed the living room to be neat and clean along with the dining room. The facility maintains a comfortable temperature at 75°F. The smoke detectors were tested and observed to be operational at 10:41am. The carbon monoxide was observed to be operational at 10:50am. There are two (2) fire extinguishers, located in the kitchen. Fire extinguishers were observed to be full and last serviced on 08/06/21. Medication cabinet was located in kitchen and at 10:25 am; was observed to be locked and inaccessible to residents in care.
Garage
LPA observed the garage to be attached to the facility and currently being used for an extra storage, resident files, extra PPE supplies, and a resting area for staff.

Administrative: LPA collected Certificate of Liability Insurance and LIC.500. Annual fee is current.

An exit interview was conducted, and a copy of this report was given to the Administrator.

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
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/28/2021 11:26 AM - It Cannot Be Edited


Created By: Shira Stamps On 12/28/2021 at 11:04 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: CAMPOS CARE HOME
FACILITY NUMBER: 191221067

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/28/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)
87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above due to cleaning supplies being accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/07/2022
Plan of Correction
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 Administrator locked the chemicals at the time of the visit upon request. The Administrator has agreed to provide in house training and provide training materials regarding this regulation to LPA by e-mail by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Nichelle Gillyard
LICENSING EVALUATOR NAME:Shira Stamps
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2021


LIC809 (FAS) - (06/04)
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