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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191221067
Report Date: 08/02/2023
Date Signed: 08/03/2023 08:04:25 AM

Document Has Been Signed on 08/03/2023 08:04 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
WOODLAND HILLS S.ASC, 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: 5DATE:
08/02/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Campos FelixTIME COMPLETED:
08:29 AM
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LPA Spaeth conducted an unannounced visit and was greeted by caregiver LPA and Caregiver toured the facility at 8:00 until 8:15 am. LPA observed the facility has a seven day supply of non perishable food and a two day supply of perishable food.

The Administrator arrived at 8:10 am. LPA stated the purpose of the visit was to conduct an unannounced visit. The Administrator stated that the second bathroom has a leak and repair work is being completed on the tub area. LPA observed the first bathroom is properly working and is available for residents to use.

There are no deficiencies to report. Exit interview conducted, and a copy of the report was given to the Administrator.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2023
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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