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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191221067
Report Date: 04/05/2024
Date Signed: 04/05/2024 04:10:06 PM

Document Has Been Signed on 04/05/2024 04:10 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/
DIRECTOR:		CECILIA T. CAMPOSFACILITY TYPE:
735
ADDRESS:226 E. AVENUE Q-3TELEPHONE:
(661) 274-9509
CITY:PALMDALESTATE: CAZIP CODE:
93550
CAPACITY: 6CENSUS: 6DATE:
04/05/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Felix CamposTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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On 4/04/2024 Licensing Program Analyst (LPA) Melissa Spaeth conducted a subsequent complaint investigation at the above facility regarding complaints #31-AS-20240326122528 & #31-AS-20240402155343. LPA Spaeth was met by the Administrator Felix Campos.

During the investigation, the Administrator stated the needs of a client could not be met at the facility. The Administrator stated they had informed the client and the client’s social worker that the client must find another living situation. The Administrator stated they had not provided an eviction notice to the client. The client was interviewed by LPA Spaeth on 4/04/2024 at 4:45 pm and the client stated they had not received a written eviction notice.

During LPA Spaeth’s visit on 4/03/2024, the Administrator stated two clients’ records were locked in the facility van and were not available for LPA to review.

Based upon the Title 22 regulations, the following deficiencies have been issued.



Exit interview conducted, appeal rights discussed, and a copy of the report was given.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/05/2024
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 04/05/2024 04:10 PM - It Cannot Be Edited


Created By: Melissa Spaeth On 04/05/2024 at 10:18 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: 04/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/08/2024
Section Cited
CCR
80068.5(a)

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80068.5 Eviction Procedures (a) Except for children’s residential facilities, the licensee may, upon 30 days written notice to the client, evict the client only for one or more of the following….This requirement is not met as evidenced by:
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The Administrator/Licensee will provide a written 30-day notice to the client.
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Based on LPA Spaeth's interview of the Administrator/Licensee, the Administrator/Licensee did not comply with the section cited above. The Administrator/Licensee failed to provide a written 30 day which poses an immediate health, safety or personal rights risk to persons in care
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Type A
04/08/2024
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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The Administrator/licensee will locate the client's file. If unable to find the file, the Administrator/Licensee will send an email to LPA Spaeth regarding the loss of the file.
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Based on LPA Spaeth's review of client records, the Administrator was unable to provide the client's records for LPA's review, which poses an immediate health, safety or personal rights risk to persons 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: 04/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2024


LIC809 (FAS) - (06/04)
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