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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191221067
Report Date: 04/05/2023
Date Signed: 04/05/2023 04:54:14 PM

Document Has Been Signed on 04/05/2023 04:54 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:
04/05/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Estephania RomeroTIME COMPLETED:
03:30 PM
NARRATIVE
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LPA Spaeth arrived to the facility and stated the purpose of the visit was a case management visit regarding required plan of corrections were completed by the Licensee. LPA was greeted by caregiver and LPA stated the purpose of the visit.

On 3/10/2023, Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced case management visit. The purpose of the 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. During LPA's visit, LPA observed a deficiency which was cited on 3/10/2023. The following deficiencies were not corrected:

- During the 3/02/2023 case management visit, the Administrator was required to complete twenty (20) hours of vendorized training and send an updated LIC500 with proof of training to reflect the hours. The deficiency was to be cleared as of March 16, 2023

- LPA Spaeth observed a resident was left alone on 3/10/2023 without staff present to meet R1's needs. Licensee was to provide a staff work schedule to LPA Spaeth. LPA Spaeth did not receive the staff work schedule. The deficiency was not cleared as of March 14, 2023 but during today's visit, a copy of the LIC 500 was provided to LPA Spaeth



Therefore, the following deficiencies are again issued per CA Code of Regulations, Title 22. See LIC809D.

Exit interviewed discussed, appeal rights were given to the caregiver and a copy of the signed report was given to caregiver.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 04/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/05/2023
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 04/05/2023 04:54 PM - It Cannot Be Edited


Created By: Melissa Spaeth On 04/05/2023 at 02:31 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: 04/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/05/2023
Section Cited
CCR
80065(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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During LPA's visit, LPA received the LIC 500.
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During LPA's visit on 3/10/2023, LPA observed a resident was left alone without staff present to meet R1's needs. This poses a potential health, safety, or personal rights risk to clients in care.
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Type B
04/06/2023
Section Cited
CCR80064(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 he receives 20 hours of vendorized training and send an updated LIC500 with proof of training to reflect his hours.
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Based on teams observation and record review on 3/02/2023, the licensee did not ensure 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
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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:Cassandra Harris
LICENSING EVALUATOR NAME:Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2023


LIC809 (FAS) - (06/04)
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