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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191221067
Report Date: 03/02/2023
Date Signed: 03/02/2023 02:30:04 PM

Document Has Been Signed on 03/02/2023 02:30 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:
03/02/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Estephania Romero - Staff - TIME COMPLETED:
02:45 PM
NARRATIVE
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On 3/2/2023 at 10:30 a.m., Licensing Program Analyst (LPA) Melissa Ruiz along with Regional Manager (RM) Angela Kendrick and Licensing Program Manager (LPM) Nichelle Gillyard arrived at the facility to conduct an unannounced case management visit. The purpose of this visit was to follow up on observations previously reported during various licensing inspections dating from July – September 2022. Upon arrival, the team was greeted by a staff member (S1) and was allowed entrance to the facility. S1 was not wearing a surgical mask and was prompted by the LPM to wear a mask. LPA attempted to contact the licensee Felix Campos various times, and the licensee informed LPA Ruiz that he was at a medical appointment and would attempt to arrive later.

At 10:40 a.m. the team conducted a physical plant tour, and interviewed the one client in care. The following was observed:

The common areas, kitchen, bathrooms, and bedrooms were dirty with visible dirt build up and trash. The walls and ceilings were in poor repair with holes. These observations were an immediate health and safety concern. At approximately 11:00 a.m., the team toured the outside of the facility and observed old furniture, and various items laying around such as wood, metal, and clothes.

At 11:10 a.m., the team conducted record review and for three clients and one staff (S1). The staff records for S1 did not have a LIC308 on file, no medication training, general training, or record of a TB test. Three of the six client records did not have updated physician reports, medication records and the records reviewed have information for a different facility that the Licensee is or has been associated with. The team observed one client (C1) to be on an oxygen tank, however no signage was observed. Deficiencies issued per CA Code of Regulations, Title 22. See LIC9099D. Report signed and delivered. Appeal rights issued.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE: DATE: 03/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/02/2023
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 03/02/2023 02:30 PM - It Cannot Be Edited


Created By: Melissa Ruiz On 03/02/2023 at 12:01 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: 03/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/04/2023
Section Cited
CCR
80087(a)

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80087 Buildings 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.

This requirement is not met as evidenced by:
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The licensee shall submit a plan to get the facility clean, safe, sanitary and within compliance under 80087(a). This plan along with photographic documentation of all cleaning and repairs to be submitted by 4/6/23 to the Woodland Hills Regional Office by the POC due date.
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Based on teams' observations of dirty walls, bathrooms, bedrooms, kitchen and common rooms, along with trash outside the facility, this poses an immediate health, safety, or personal rights risk to clients in care.
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Type A
03/04/2023
Section Cited
CCR80066(a)(11)

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80066 Personnel Records A (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator, and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).


This requirement is not met as evidenced by:
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The licensee shall ensure staff 1 and all future staff complete a TB test. Proof of TB test documentation to be submited by the POC due date.
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Based on record review, staff #1 did not have a Tuberculosis test documented in their staff file. This poses an immediate health, safety, or personal rights 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:Melissa Ruiz
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2023


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 03/02/2023 02:30 PM - It Cannot Be Edited


Created By: Melissa Ruiz On 03/02/2023 at 12:59 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: 03/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/04/2023
Section Cited
CCR
85076(d)(1)

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85076 Food Service (d) The licensee shall meet the following food supply and storage requirements: (1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premise.

This requirement is not met as evidenced by:
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The licensee shall purchase sufficient food, a copy of receipt and photo documentation of sufficient food shall be submitted by the POC due date.
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Based on teams observations, insufficient food, within the regulation was observed for a total of six clients in care. This poses an immediate health, safety, or personal rights risk to clients in care.
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Type A
03/04/2023
Section Cited
CCR80065(a)

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80065 Personnel Requirements (a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.

This requirement is not met as evidenced by:
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The licensee shall submit a plan to hire additional staffing shall be hired. The Licensee shall ensure new staff are hired and trained under regulation 80065(a) within 30 days and send an updated LIC500 .
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Based on the teams observation and an interview with S1, there is insufficient staffing to meet the clients' needs as the Licensee is the only one to relieve S1, and S1 works 12 hour days. This poses an immediate health, safety, or personal rights 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:Melissa Ruiz
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2023


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 03/02/2023 02:30 PM - It Cannot Be Edited


Created By: Melissa Ruiz On 03/02/2023 at 01:11 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: 03/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/09/2023
Section Cited
CCR
85095.5(c)(1)(F)

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85095.5 Infection Control Requirements (c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022. (1) The Infection Control Plan shall include all of the following: (F) Staff shall demonstrate knowledge of and skill in infection control, as appropriate to the job assigned and as evidenced by safe and effective job performance.


This requirement is not met as evidenced by:
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The licensee and staff shall submit training provided by someone certified for infection control. This training is to be signed and submitted by the POC due date.
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Based on teams' observations, Staff #1 was observed to not be wearing a surgical mask and was prompted to wear one by the team. This poses a potential health, safety, or personal rights risk to clients in care.
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Type B
03/09/2023
Section Cited
CCR80065(f)

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80065 Personnel Requirements (f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance.

This requirement is not met as evidenced by:
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The licensee shall ensure all the proper training is done for S1 and all staff. Documents of training for each and all staff to be submitted by the POC due date.
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Based on record review, the licensee did not ensure staff had proper documentation to reflect training regarding medication and general training. This poses a potential health, safety, or personal rights 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:Melissa Ruiz
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2023


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 03/02/2023 02:30 PM - It Cannot Be Edited


Created By: Melissa Ruiz On 03/02/2023 at 01:20 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: 03/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/09/2023
Section Cited
CCR
80070(a)

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80070 Client Records (a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.

This requirement is not met as evidenced by:
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The licensee shall update six out of six client records and ensure updated and accurate documentation is kept for each client. Documentation is to be provided by the POC due date.
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Based on record review, three out of six client records were observed to have missing our outdated physician reports, appraisals, or medication records. This poses a potential health, safety, or personal rights risk to clients in care.
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Type B
03/09/2023
Section Cited
CCR80075(e)(2)(B)

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80075 Health Related Services (e) In adult CCFs, when a client requires oxygen the licensee is responsible for the following: (2) Ensuring that the following conditions are met if oxygen equipment is in use: (B) "No Smoking - Oxygen in Use" signs shall be posted in appropriate areas.

This requirement is not met as evidenced by:
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The licensee shall post an oxygen in use signage where appropriate throughout the outside and inside the facility. Licensee to send photographic pictures of signage.
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Based on the teams observation, there was no appropriate signage regarding a client using a oxygen tank. This poses a potential health, safety, or personal rights 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:Melissa Ruiz
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2023


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 03/02/2023 02:30 PM - It Cannot Be Edited


Created By: Melissa Ruiz On 03/02/2023 at 01:37 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: 03/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/16/2023
Section Cited
CCR
80064(a)(3)

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80064 Administrator - Qualifications and Duties (a) The administrator shall have the following qualifications: (3) Knowledge of and ability to comply with applicable law and regulation.

This requirement is not met as evidenced by:
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The licensee shall ensure they receive 20 hours of vendorized training within two weeks and send an updated LIC500 with proof of training to reflect his hours.
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Based on teams observation, record review and interviews, the licensee did not ensure that they were qualified or knowledgeable enough to administrate the facility and oversee clients in care. This poses a potential health, safety, or personal rights 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:Melissa Ruiz
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2023


LIC809 (FAS) - (06/04)
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