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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191221067
Report Date: 09/13/2023
Date Signed: 09/13/2023 03:29:17 PM

Document Has Been Signed on 09/13/2023 03:29 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
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: DATE:
09/13/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Felix CamposTIME COMPLETED:
02:30 PM
NARRATIVE
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LPA Melissa Spaeth and LPA Gina Saucedo conducted an unannounced visit. Upon arrival, LPAs were greeted by a client (C1) who stated Administrator had left the facility for a few minutes but would be returning. C1 stated the live-in staff was asleep in the staff room. LPA called Administrator at 9:30 am and left a message. C1 stated was a new client and moved in about 9/01/2023 At 9:35 am, C1 invited LPAs to enter the facility and LPA Spaeth knocked at the staff room's door. However, no one responded to the knock and LPAs did not know if the live in staff was at the facility. LPAs also knocked at the exterior door that led to the staff room; however, no one responded.

The Administrator arrived at 10:20 am. LPA Spaeth stated the purpose of the visit was to conduct a case management tour and LPAs were accompanied by the Administrator at 10:25 am for the tour. LPA Spaeth asked Administrator the move-in date of C1. Administrator stated C1 was a hired construction worker to assist with the remodeling of bathroom #2. LPA stated upon arrival, C1 confirmed was a new client as of 9/01/2023. LPA asked Administrator to confirm. Administrator stated C1 was actually a resident but was assisting Administrator with the remolding process.

LPA asked for client’s file but Administrator did not have the file at the facilty. LPA also stated the client should not be assisting with the remodeling process since C1 is a resident. LPA also stated based upon Title 22 regulations, client files must be available for LPAs review. The Administrator failed to provide the documentation to the LPAs during the visit.

Also, the Administrator asked C1 to leave the facility during LPAs’ visit and C1 left at 10:45 am. LPAs asked if Administrator knew where client was going but Administrator stated did not know.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2023
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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: CAMPOS CARE HOME
FACILITY NUMBER: 191221067
VISIT DATE: 09/13/2023
NARRATIVE
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LPAs observed the knives and medications were locked in the kitchen cabinet. LPA requested to view the facility menu but observed the current menu posted was dated June, 2023. LPA requested Administrator to submit the September, 2023 calendar to LPA Spaeth via email. LPAs observed bathroom #1 was still under construction but bathroom #2 is available for residents’ use.

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: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/13/2023 03:29 PM - It Cannot Be Edited


Created By: Melissa Spaeth On 09/13/2023 at 11:59 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: 09/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/14/2023
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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LPA Spaeth instructed Administrator send the LIC 500 to LPA via email. LPA Spaeth confirmed Administrator understands staff supervision means staff are awake and physically present.
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Upon entering the facility, LPA observed a client was alone without staff available for supervision. This poses a potential health, safety, or personal rights risk to clients in care.
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Type A
09/18/2023
Section Cited
CCR80070(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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Administrator will provide a copy of the following resident records to LPA Spaeth via email: 1) Consent for Emergency Medical Treatment, 2) Appraisal Needs & Services, 3) I/D Emergency Form 4) Client/Resident Property & Valuables.
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LPA's requested to review C1's file however, the file was not complete. 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:Troy Agard
LICENSING EVALUATOR NAME:Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 09/13/2023 03:29 PM - It Cannot Be Edited


Created By: Melissa Spaeth On 09/13/2023 at 12:37 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: 09/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/14/2023
Section Cited
CCR
80076(a)(5)

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80076 (a) In facilities providing meals to clients, the following shall apply: (5) Menus shall be written at least one week in advance and copies of the menus as served shall be dated and kept on file for at least 30 days. Menus shall be made available for review…
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Administrator will send September, 2023 calendar to LPA Spaeth via email.
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 This requirement is not met as evidenced by: LPAs observed the posted menu was dated June, 2023. Administrator confirmed has not written an updated menu since Jun3, 2023.
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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:Troy Agard
LICENSING EVALUATOR NAME:Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2023


LIC809 (FAS) - (06/04)
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