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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191221067
Report Date: 09/19/2024
Date Signed: 09/19/2024 11:09:33 AM

Document Has Been Signed on 09/19/2024 11:09 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/
DIRECTOR:		CECILIA T. CAMPOSFACILITY TYPE:
735
ADDRESS:226 E. AVENUE Q-3TELEPHONE:
(661) 274-9509
CITY:PALMDALESTATE: CAZIP CODE:
93550
CAPACITY: 6CENSUS: 5DATE:
09/19/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:15 AM
MET WITH:Felix CamposTIME VISIT/
INSPECTION COMPLETED:
08:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced visit as of today, 9/19/2024. LPA was greeted by the licensee, Felix Campos. LPA Spaeth stated the purpose of the visit was to tour the facility and discuss the missing client’s (C1) file.

LPA Spaeth stated an unannounced visit was conducted on 8/09/2024 regarding complaint # 31-AS-20240403084551. During the visit, LPA observed a C1’s file was missing. The Licensee explained C1’s file was in the facility van and the van was stolen. The Licensee confirmed C1’s file is still missing.

LPA toured the facility at 7:30 am until 7:45 am and observed there was not an adequate supply of non-perishable food items. Also, the kitchen table was dirty and the kitchen floor, and kitchen sink were dirty. Also, LPA Spaeth observed the light in the kitchen was not working. During LPA's visit, LPA observed the Administrator replaced the light. LPA discussed with the Licensee the facility must be clean at all times and there should be an adequate supply of food for the clients.

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: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/18/2024
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 09/19/2024 11:09 AM - It Cannot Be Edited


Created By: Melissa Spaeth On 09/18/2024 at 04:18 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: 09/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/19/2024
Section Cited
CCR
80070(a)

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80070 Client Records (a) The licensee shall ensure that a separate, complete & current record is maintained in the facility for each client. This requirement is not met as evidenced by:
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Administrator will ensure the clients files are securely kept in a locked cabinet in the facility. LPA also stated the clients' files should not be left in any vehicle..
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Based on LPA Spaeth's review of the clients' file, LPA observed C1's file was missing. The Administrator/Licensee failed to ensure the client's records were secure in the facility, which poses an immediate health, safety or personal rights risk to persons in care
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Type B
09/20/2024
Section Cited
CCR80076(a)(1)

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80076 Food Services (a) In facilities providing meals to clients, the following shall apply: (1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. This requirement is not met as evidenced by:
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The Administrator will purchase perishable food items and send a snapshot to LPA Spaeth.
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LPA Spaeth observed there was not an adquate supply of non-perishable food items such as milk, eggs, fresh vegetables and fresh fruits.
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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: 09/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/19/2024 11:09 AM - It Cannot Be Edited


Created By: Melissa Spaeth On 09/19/2024 at 08:08 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: 09/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/20/2024
Section Cited
CCR
80087(a)

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80087 Buildings & 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:
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The Administrator will clean the kitchen, dining room table, and sweep the floor. The Administrator will send a snapshot of the kitchen sink, kitchen floor, and the kitchen table after cleaning.
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Based on LPA Spaeth's tour, LPA observed the kitchen floor, dining room table, and kitchen sink were dirty 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: 09/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2024


LIC809 (FAS) - (06/04)
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