191221067-4-5-2024-31-AS-MVAO-D46VAE-20240409161551

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191221067
Report Date: 04/05/2024
Date Signed: 04/05/2024 04:13:50 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/26/2024 and conducted by Evaluator Melissa Spaeth

COMPLAINT CONTROL NUMBER: 31-AS-20240326122528

FACILITY NAME:	CAMPOS CARE HOME		FACILITY NUMBER:	191221067
ADMINISTRATOR:	CECILIA T. CAMPOS		FACILITY TYPE:	735
ADDRESS:	226 E. AVENUE Q-3		TELEPHONE:	(661) 274-9509
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93550
CAPACITY:	6	CENSUS: 6	DATE:	04/05/2024
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Felix Campos		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff harass resident(s) in care.
Staff threaten resident(s) in care.
Staff do not ensure that resident(s) are administered their medication(s) as prescribed.

INVESTIGATION FINDINGS:

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On 4/04/2024 Licensing Program Analyst (LPA) Melissa Spaeth conducted a subsequent complaint investigation at the above facility to address the following allegation(s). LPA Spaeth was met by the Administrator Felix Campos. LPA explained the purpose of this visit was to deliver the findings for this complaint.

The investigation consisted of the following: On 4/03/2024 LPA Spaeth initiated a complaint investigation. LPA toured the physical plant at 11:00 am until 11:20 am. LPA reviewed resident records at 11:20 am until 11:40 am. LPA requested the resident roster, residents’ medication logs, and staff phone numbers. LPA Spaeth received the documentation on 4/03/2024. LPA Spaeth interviewed six out of six residents and one staff member out of three staff members. Two staff members refused to be interviewed.

Cont. on 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20240326122528

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/05/2024

NARRATIVE

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The investigation revealed the following: Regarding the allegation, staff harass resident(s) in care. It’s being alleged the Administrator initiates an argument with a client so that the client will react and hit the Administrator. Two clients out of six clients stated they have witnessed arguments between a client and the Administrator. Four clients out of the six clients stated they did not witness this type of incident. S2 stated they had not witnessed this behavior. The Administrator denied the allegation.

Regarding the allegation staff threaten resident(s) in care. It’s being alleged a client feels threatened by the Administrator. The six clients interviewed stated they do not feel threatened by the Administrator. S2 stated they had not witnessed this behavior. The Administrator denied the allegation.

Regarding the allegation Staff do not ensure that resident(s) are administered their medication(s) as prescribed. It’s being alleged the Administrator frequently distributes the clients’ medications at a late time during the evening hours. Five clients out of the six clients stated the Administrator distributes the medications after dinner and never distributes the medications later in the evening. C1 stated the late medication distribution did occur. LPA Spaeth observed the six clients’ medication logs. The logs revealed the clients received their daily medications at the prescribed times. S1 and S2 stated the six clients have never stated they did not receive their medications as prescribed. S2 stated they have never distributed clients’ medications at a late time during the evening hours.

Based on the record review and interviews of the clients and the staff member, the allegations are unsubstantiated.

Exit interview conducted and a copy of the report was given.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2024

LIC9099 (FAS) - (06/04)

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