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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191221067
Report Date: 05/07/2023
Date Signed: 05/07/2023 04:01:32 PM

Document Has Been Signed on 05/07/2023 04:01 PM - 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:
05/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:41 PM
MET WITH:Florida Malla - designeeTIME COMPLETED:
04:00 PM
NARRATIVE
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An unannounced One (1) year Required visit was conducted on this day by Licensing Program Analyst (LPA) Gary Tan. LPA met with staff Estephania Romero who called the son of the administrator Aaron Campos and explained the purpose of the visit. LPA was informed that the administrator, Felix Campos is currently out of the country. Mr. Aardon Campos called his aunt Florida Malla who arrived at the facility 30 minutes later.

LPA conducted physical plant tour inside and out at 1:00 PM. During the tour, LPA observed that the facility has four (4) bedrooms and two (2) bathrooms. Three (3) shared bedrooms and one (1) bedroom and one (1) bathroom is designated for staff use. There is no body of water in the facility.

Bedrooms were toured and observed to be clean and appropriately furnished.
Bathrooms were observed to be clean, sanitary and with necessary supplies. Hot water temperature was measured at 118.9°F. Bathroom sink has a leak and in disrepair
Physical plant was checked for cleanliness and condition.
Living and dining room furniture were also checked for functionality (wear and tear). Furniture was observed to be in good condition.
Kitchen area is observed to be clean and sanitary. Knives and sharps are locked and secured in the cabinet below the kitchen sink.
Food. The facility is observed to have sufficient food supply for clients.
Temperature of facility wall thermostat was set at 75.0°F and observed to be within the required range.
Fire extinguisher One (1) current fire extinguisher was observed to be located in the dining room area. Fire alarms are battery operated. There was a carbon monoxide installed in the facility, located in the hallway.

Medication were observed to be locked, inaccessible and stored in the kitchen. There are two (2) complete first aid kits locked and maintained in the kitchen cabinet.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 05/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/07/2023
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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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: 05/07/2023
NARRATIVE
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(continued from LIC 809)

Garage - There is no garage at the facility, only car ports

Laundry Area: The laundry area is located at the back space/extension of the facility. No cleaning supplies were observed accessible.

Client records were reviewed. Four (4) out of six (6) clients have no Physician's report on file (LIC 602)

Staff records were also reviewed. Staff present has criminal record clearances and associated to this facility.

There was no record of disaster drill on file. Required posting observed in facility (complaint hot line poster, personal rights, etc).

Citation issued. Appeal rights discussed and given. Exit interview conducted. Copy of this report issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 05/07/2023 04:01 PM - It Cannot Be Edited


Created By: Jose Gary Tan On 05/07/2023 at 01:55 PM
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: 05/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(3)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (3) All toilets, handwashing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above. LPA observed that there was a leak on the bathroom sink of clients' bathroom which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/18/2023
Plan of Correction
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Administrator designee agreed to repair the leak on the bathroom and submit proof of repair to CCL on or before the POC date.
Type B
Section Cited
CCR
85068.2(b)(1)(C)
Needs and Services Plan
(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (C) The written medical assessment specified in Section 80069.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's record review at 2:00 PM, the licensee did not comply with the section cited above in 4 out of 6 clients did not have physician's report on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/18/2023
Plan of Correction
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Administrator designee agreed to obtain the LIC 602 for the four residents and submit a copy to to CCL on or before the POC date.
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:Naira Margaryan
LICENSING EVALUATOR NAME:Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:
DATE: 05/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 05/07/2023 04:01 PM - It Cannot Be Edited


Created By: Jose Gary Tan On 05/07/2023 at 01:55 PM
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: 05/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's record review at 2:40 PM the licensee did not comply with the section cited above as there was no record of any fire drill at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/18/2023
Plan of Correction
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Administrator designee agreed to conduct a fire/disaster drill ASAP and submit a proof of the drill attendance on or before the POC 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:Naira Margaryan
LICENSING EVALUATOR NAME:Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:
DATE: 05/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2023


LIC809 (FAS) - (06/04)
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