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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191221067
Report Date: 06/06/2023
Date Signed: 06/07/2023 08:37:11 AM

Document Has Been Signed on 06/07/2023 08:37 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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: 5DATE:
06/06/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:01 PM
MET WITH:Estephania RomeroTIME COMPLETED:
05:30 PM
NARRATIVE
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LPA Spaeth arrived to the facility at 3:01 pm to conduct a case management visit. LPA was greeted by a client (C1) at the front door. C1 stated the staff members were not at the facility and there was another client (C2) also there. C1 stated was awaiting the return of the staff members.

At 3:20 pm, LPA observed the facility van arrived. The two staff members (S1 and S2) stated picked up three residents at the day program, LPA stated to S1 and S2 two residents were alone at the facility and that a staff member should have been at the facility.

LPA asked if Administrator had returned to the facility. S2 stated Administrator was still out of the country and that Florida Malla was filling in during Administrator's absence.

Also, CCL did not previously receive notification from the Administrator stating the Administrator would be out of the country as of March 26, 2023. Also, it is undetermined when the Administrator will be returning.

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

Exit interview conducted, appeal rights were given to the caregiver and a copy of the signed report was given to caregiver.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 06/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2023
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 06/07/2023 08:37 AM - It Cannot Be Edited


Created By: Melissa Spaeth On 06/06/2023 at 04:29 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: 06/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/09/2023
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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The acting Administrator will instruct current staff members to determine who will stay at the facility while other staff member picks up residents at the adult care program. The acting Administrator will submit to LPA a written notification when this was completed
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Upon entering the facility, LPA observed a two clients (C1 & C2) were left alone without any staff present to meet C1 & C2's needs. This poses a potential health, safety, or personal rights risk to clients in care.
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Type A
06/09/2023
Section Cited
CCR80066(d)

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80066 Personnel Records (d) licensing agency to inspect, audit, and copy upon demand during normal business hours…This requirement was evidenced by:
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Acting Administrator will provide documentation regarding the Administrator's decision to request the services of the acting Administrator.
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Administrator failed to provide notification to CCL that Administrator was leaving the country as of 3/26/2023. The Administrator did not provide acting Administrator's Administrator Certificate or written notification to CCL regarding this issue.
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Facility staff will ensure written documentation stating the name of the acting Administrator. Facility staff will send a snapshot of the written documentation to LPA Spaeth via email.
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:Troy Agard
LICENSING EVALUATOR NAME:Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2023


LIC809 (FAS) - (06/04)
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