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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191221067
Report Date: 09/29/2022
Date Signed: 09/29/2022 02:27:26 PM

Document Has Been Signed on 09/29/2022 02:27 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: 6DATE:
09/29/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Felix Campos, LicenseeTIME COMPLETED:
02:35 PM
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At 10:30 am, Licensing Program Analyst (LPAs) Shira Stamps and Angela Panushkina conducted a case management visit. Entrance interview conducted with the Licensee.

The purpose of this visit is to verify the facilities capacity. LPAs arrived and entered the property. LPAs contacted the Licensee at 10:45 am and he stated there was a staff member at the facility, and he was at the doctor. LPA entered the home and conducted a physical plant tour and verified that the facility currently has six (6) clients living in the home. On 7/08/22, the facility was cited for not having a certified Administrator, and on 7/15/22 the plan of correction (POC) was cleared. As of today’s, visit, the Administrator has quit and no longer works for the facility. The Licensee stated he has applied for his Administrator Certificate and paid the fee. LPA conducted a file review and verified with the Community Care Licensing Division Administrator Certification that the Licensee does not have an active or pending application for his Administrator Certificate. The facility currently has no certified Administrator (repeat violation).

Exit interview conducted. Civil Penalties and Citations issued. Appeal rights and copy of report delivered to Licensee.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2022
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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Document Has Been Signed on 09/29/2022 02:27 PM - It Cannot Be Edited


Created By: Shira Stamps On 09/29/2022 at 02:08 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: 09/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/06/2022
Section Cited
CCR
85064(b)

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85064 Administrator Qualifications and Duties (b) All adult residential facilities shall have a certified administrator.

This requirement is not met as evidenced by
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Licensee will hire a certified Administrator, provide the necessary documents for Administrator, and provide an updated LIC 500 to reflect the Administrator's hours by the POC due date.
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Based on interviews the Licensee did not comply with the section cited above in that the Licensee did not ensure there was a certified Administrator to manage the facility, 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: 09/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2022


LIC809 (FAS) - (06/04)
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