191221067-3-10-2023-31-AS-MSPH-CPT36Z-20230310165910

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191221067
Report Date: 03/10/2023
Date Signed: 03/10/2023 04:59:24 PM

Document Has Been Signed on 03/10/2023 04:59 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 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:	DATE:	03/10/2023
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Felix Campos		TIME COMPLETED:	12:15 PM

NARRATIVE

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On 3/10/2023 at 9:45, Licensing Program Analyst (LPA) Melissa Spaeth arrived at the facility to conduct an unannounced case management visit. The purpose of this visit was to determine if the deficiencies cited on the previous case management visit that took place on 3/2/2023 by LPA Ruiz, Regional Manager Kendrick and LPM Gillyard had been corrected.

LPA and Licensee toured the facility at 10:00 am until 10;15 am. LPA observed a resident (R1) was in bedroom but no caregiver was present. Licensee stated stepped out for a few minutes. LPA stated that residents are not to be left alone within the facility.

During LPA's visit, LPA reviewed the following deficiencies with the License:

The licensee did not provide an update that six out of six client records were updated and that accurate documentation is located in each client file. Proof of correction was not provided to LPA by the POC date of 3/09/2023.

The licensee did not provide documentation that staff 1 completed a TB test. Licensee was unable to provide the documentation. Proof of correction was not provided to LPA by the POC date of 3/04/2023.

The licensee did not purchase sufficient food, did not provide a copy of receipt and did not provide photo documentation of sufficient food to the LPA. Proof of correction was not provided to LPA by the POC date of 3/04/2023.

The licensee did not submit a plan to hire additional staffing. Proof of correction was not provided to LPA by the POC date of 3/04/2023

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 HOME	FACILITY NUMBER: 191221067
	VISIT DATE: 03/10/2023

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The licensee and staff did not complete training by a certified infection control vendor or person. Proof of correction was not provided to LPA by the POC date of 3/09/2023.

The licensee did not ensure all the proper required training was completed for S1 and all staff. Proof of correction was not provided to LPA by the POC date of 3/09/2023.

The licensee did not submit a plan to get the facility clean, safe, sanitary and within compliance under 80087(a). Proof of correction was not provided to LPA by the POC date of 3/09/2023

At 10:30 am, LPA observed Licensee paid outstanding licensee fee online. LPA reminded Licensee that photographic documentation of all cleaning and repairs must be submitted to LPA Spaeth by 4/06/2023.

A deficiency was issued per CA Code of Regulations, Title 22. See LIC9099D.

Exit interviewed discussed, appeal rights were given to Licensee and a copy of the signed report was given to Licensee.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/10/2023 04:59 PM - It Cannot Be Edited

Created By: Melissa Spaeth On 03/10/2023 at 11:17 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: 03/10/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/14/2023 Section Cited CCR 80065(a)	1 2 3 4 5 6 7	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:	1 2 3 4 5 6 7	Licensee will provide a staff work schedule.
	8 9 10 11 12 13 14	Upon entering the facility, LPA observed a resident was left alone without any staff present to meet R1's needs. This poses a potential health, safety, or personal rights risk to clients in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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:

Cassandra Harris

LICENSING EVALUATOR NAME:

Melissa Spaeth

LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023

LIC809 (FAS) - (06/04)

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