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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191221067
Report Date: 01/04/2024
Date Signed: 01/05/2024 07:42:07 AM

Document Has Been Signed on 01/05/2024 07:42 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: DATE:
01/04/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Felix CamposTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced visit. Upon arrival, LPAs were greeted the Administrator Felix Campos. LPA stated the purpose of the visit was to tour the facility..

LPA Spaeth toured the facility with the Administrator at 3:00 pm until 3:20 pm. LPA Spaeth observed there was a two-day supply of perishable foods and a seven-day supply of non-perishable foods. LPA Spaeth also observed the facility was clean.

There are no deficiencies to report at this time. Exit interview conducted and a copy of the signed report was given to the Administrator.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 01/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/04/2024
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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