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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191221067
Report Date: 12/20/2024
Date Signed: 12/20/2024 02:48:05 PM

Document Has Been Signed on 12/20/2024 02:48 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/
DIRECTOR:		CECILIA T. CAMPOSFACILITY TYPE:
735
ADDRESS:226 E. AVENUE Q-3TELEPHONE:
(661) 274-9509
CITY:PALMDALESTATE: CAZIP CODE:
93550
CAPACITY: 6CENSUS: 5DATE:
12/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Felix CamposTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced annual visit on 12/20/2024. LPA was greeted by the Administrator Felix Campos and a staff member. The facility is licensed for six ambulatory residents and the Administrator confirmed there are five residents living in the facility. LPA did not observe clients at the facility and the Administrator confirmed three clients were attending the adult day program and two were taking care of their personal business today.

LPA Spaeth and the Administrator began the tour at 9:00 am until 9:40 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. The cleaning solutions, knives, client files, and medications were locked in a file cabinet. LPA observed dead roaches in a kitchen cabinet.



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

Bathrooms – LPA observed the bathrooms contained hand soap, paper towels, and covered trash cans. Tiles were missing in the client bathroom and the Administrator confirmed repair work is being done. The clients are able to shower in the second bathroom.



Continued on 809-C
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: 12/20/2024
NARRATIVE
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Water Temperature – LPA Spaeth tested the water at 9:30 am and the temperature was 122.0 degrees F.

Staff Room - The staff room was locked and the Administrator confirmed the staff member worked the night shift and was sleeping.

Backyard - LPA observed a shaded area is available for the clients.

Smoke Detector and Carbon Monoxide Detectors - LPA observed both detectors were working at 9:40 am.

LPA reviewed the resident records at 11:45 am until 12:15 pm and reviewed the staff records at 12:15 pm until 12:40 pm. LPA reviewed client medications at 1:00 pm until 1:15 pm.

Based upon the Title 22 regulations, the following deficiencies have been issued.



Exit interview conducted, appeal rights discussed, and a copy of the report was given.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 12/20/2024 02:48 PM - It Cannot Be Edited


Created By: Melissa Spaeth On 12/20/2024 at 12:48 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: 12/20/2024

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's observation, the licensee did not comply with the section cited above. The water temperature was tested and was 122.0 Degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/20/2024
Plan of Correction
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During LPA's visit, the water temperature was adjusted. LPA tested the water at 12:50 pm and the recorded temperature was 105 degrees F.
Type A
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's review of staff files, the licensee did not comply with the section cited above. Two staff members have not completed the CPR/First Aid training which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/30/2024
Plan of Correction
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Licensee will ensure the two staff members have completed the CPR/First Aid training and will send photos of the CPR/First Aid training cards to LPA Spaeth via text
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: 12/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 12/20/2024 02:48 PM - It Cannot Be Edited


Created By: Melissa Spaeth On 12/20/2024 at 12:48 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: 12/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)(1)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (1) The licensee shall take measures to keep the facility free of flies and other insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above. LPA observed dead roaches in a kitchen cabinet which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/20/2024
Plan of Correction
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LPA observed the kitchen cabinet was cleaned during LPA's physcial plant inspection.
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: 12/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2024


LIC809 (FAS) - (06/04)
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