<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191221067
Report Date: 10/19/2023
Date Signed: 10/19/2023 04:13:36 PM

Document Has Been Signed on 10/19/2023 04:13 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: 4DATE:
10/19/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Felix CamposTIME COMPLETED:
03:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst Melissa Spaeth and Lorena Casillas conducted an unannounced visit. Upon arrival, LPAs were greeted the Administrator Felix Campos. LPA stated the purpose of the visit.

LPA Spaeth and Casillas toured the facility with the Administrator at 2:20 pm until 2:45 pm. LPAs observed the tile floors were dirty. At 2:35 pm, LPAs observed there was not a two-day supply of perishable foods and not a seven-day supply of non-perishable foods. The Administrator stated they have not purchased food from the grocery store but planned to go to the store later today. LPA Casillas stated the refrigerator was dirty and there was not enough food in the refrigerator.

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



Exit interview conducted, appeal rights discussed, and a copy of the signed report was given to the Administrator.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2023
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 10/19/2023 04:13 PM - It Cannot Be Edited


Created By: Melissa Spaeth On 10/19/2023 at 02:54 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: 10/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/20/2023
Section Cited
CCR
85076(d)(1)

1
2
3
4
5
6
7
85076 Food Service (d) The licensee shall meet the following food supply…requirements (1) Supplies of nonperishable foods for a minimum of one week & fresh perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator will purchase perishable and non-persishable food. Administrator will send a snapshot of the purchased food and email to LPA Spaeth.
8
9
10
11
12
13
14
Based on LPA Spaeth's view of the food supply, the licensee did not comply with the section cited above in not providing a two day supply of perishable foods which poses an immediate health, safety or personal
8
9
10
11
12
13
14
T
Type B
10/20/2023
Section Cited
CCR80087(a)

1
2
3
4
5
6
7
80087 Building 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:
1
2
3
4
5
6
7
The Administrator will mop the entire facility and send a snapshot of the living room, kitchen, bathrooms, and resident rooms to LPA Spaeth via email.
8
9
10
11
12
13
14
Based on LPAs observations, the tile floor was dirty in the living room, kitchen, bathrooms, and resident bedrooms.
8
9
10
11
12
13
14
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: 10/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2