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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191221067
Report Date: 08/04/2022
Date Signed: 08/04/2022 03:41:15 PM

Document Has Been Signed on 08/04/2022 03:41 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
CCLD Regional Office, 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:
08/04/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Felix Campos, Licensee TIME COMPLETED:
12:00 PM
NARRATIVE
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At 12:00pm, Licensing Program Analyst (LPAs) Shira Stamps and Melissa Ruiz conducted a case management visit with the Licensee in conjunction with a complaint visit. Entrance interview conducted.

The purpose of the case management is to address deficiencies observed during the complaint visit on 7/08/22. During the physical plant tour LPAs observed unlocked medications in the kitchen cabinet. LPAs also observed clients smoking in the home which can affect clients who do not smoke. Therefore, based on observations citations will be issued. Licensee refused to sign due to him leaving the facility to take clients to the doctor.

Exit interview conducted. Citations issued, appeal rights and copy of report left for Licensee.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE: DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 08/04/2022 03:41 PM - It Cannot Be Edited


Created By: Shira Stamps On 08/04/2022 at 10:57 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: 08/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/11/2022
Section Cited
CCR
80075(k)(1)

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80075(k)(1) Health Related Services Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
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The Licensee shall ensure all staff receive vendored training regarding centrally storing medication and maintaining it inaccessible to clients in care. Licensee will submit verification of training by the POC due date.
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Based on observation licensee did not ensure that medications were kept locked and inaccessible to clients in care, which poses an immediate health, safety, or personal rights risk to clients in care.
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Type B
08/11/2022
Section Cited
CCR80072(a)(2)

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80072(a)(2) Personal Rights. To be accorded safe, healthful, and comfortable accommodations, furnishings and equipment to meet his/her needs.

This requirement was not met as evidence by:
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The Licensee stated they will submit a statement that they will redirect clients to smoke in a designated area and enforce the rule of no smoking in non-smoking areas with clients.
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Based on observation the Licensee did not ensure that clients are smoking in designated smoking areas and this can affect other client who do not smoke, which poses a potential health and safety risk to clients in care.
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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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Shira Stamps
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2022


LIC809 (FAS) - (06/04)
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