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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191221067
Report Date: 12/20/2023
Date Signed: 12/20/2023 02:42:20 PM

Document Has Been Signed on 12/20/2023 02:42 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
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:
12/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Felix CamposTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced annual visit on 12/20/2023. LPA was greeted by the Administrator Felix Campos. The facility is licensed for six ambulatory residents and the Administrator confirmed there are five residents living in the facility. The Administrator confirmed all five residents are participating in an adult day program and were not present at the facility.

LPA Spaeth and the Administrator began the tour at 10:10 am until 10:35 am. LPA observed the following:

Common areas – The living room contained comfortable seating. The dining room contained a dining room table and chairs.

Kitchen – LPA observed a two-day supply of perishable food and a seven-day supply of non-perishable food. There were no cleaning solutions stored underneath the kitchen sink. A fire extinguisher was located in the kitchen area. The knives were safely locked in the kitchen area.



Resident Rooms - LPA observed the three resident rooms contained bed, linens, night stand, lamp, closet and chest of drawers.

Medications - The medications were locked in a two drawer cabinet located in the dining room.

Bathrooms – LPA observed the bathroom which contained contained hand soap, paper towels, and covered trash cans..



Water Temperature – LPA Spaeth tested the water at 10:45 am and was 126.0 degrees F.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2023
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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: CAMPOS CARE HOME
FACILITY NUMBER: 191221067
VISIT DATE: 12/20/2023
NARRATIVE
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Smoke/Carbon Monoxide Detectors – The smoke and carbon monoxide detectors were tested at 11:15 am and were operable.

Backyard - LPA observed the backyard which has a shaded area.

LPA reviewed client records at 10:40 am until 11:00 am. LPA also reviewed staff records at 11:00 am until 11:15 am.

Based upon Title 22 Regulations, the following deficiency is substantiated. (See 809-D page).

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

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/20/2023 02:42 PM - It Cannot Be Edited


Created By: Melissa Spaeth On 12/20/2023 at 11:42 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: 12/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Spaeth's observation, the licensee did not comply with the section cited above in which the water temperature was recorded at 10:45 am to be 126.8 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/20/2023
Plan of Correction
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During LPA's visit, the Administrator turned down the temperature and LPA checked the water temperature at 11:48 am and the water temperature was 120.0 F. LPA instructed Administrator to check the water temperature again this evening, 12/20/2023 and in the morning 12/21/2023. LPA also instructed Administrator to take a snapshot of the recorded water temperature guage and send to LPA Spaeth.
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:Troy Agard
LICENSING EVALUATOR NAME:Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2023


LIC809 (FAS) - (06/04)
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