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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191221067
Report Date: 10/17/2024
Date Signed: 10/17/2024 03:23:57 PM

Document Has Been Signed on 10/17/2024 03:23 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: 5DATE:
10/17/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:04 AM
MET WITH:Felix CamposTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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On 10/17/2024 Licensing Program Analyst (LPA) Melissa Spaeth conducted a complaint investigation at the above facility regarding complaint #31-AS-20241016112001.

LPA Spaeth knocked on the front door at 9:00 am and was greeted by a client. LPA observed there was not a staff member present in the facility and the client confirmed they were alone. The Administrator arrived at 9:15 am and stated they dropped off two clients at the adult day program. LPA asked if another staff member was present in the facility. The Administrator stated the caregiver who worked the night shift was probably sleeping in the attached apartment. LPA asked if there was another staff member working at the time and the Administrator stated no.

LPA and the Licensee conducted a physical plant tour at 9:00 am until 9:20 am. LPA observed there was not a two-day supply of perishable food and the kitchen floor was dirty. LPA Spaeth observed a new staff member who reported to work but was not associated to the facility. Also, LPA reviewed residents' file at 1:15 pm and observed one client's file has a missing document.



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: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2024
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 10/17/2024 03:23 PM - It Cannot Be Edited


Created By: Melissa Spaeth On 10/17/2024 at 11:12 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: 10/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/18/2024
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 and sweep the floor. The Administrator will send a snapshot of the kitchen floor.
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During LPA's tour, LPA observed the kitchen floor was dirty which poses a potential health, safety or personal rights risk to clients in care.
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Type A
10/18/2024
Section Cited
CCR80065(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 the 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 three clients were alone without staff available for supervision. 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: 10/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2024


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Document Has Been Signed on 10/17/2024 03:23 PM - It Cannot Be Edited


Created By: Melissa Spaeth On 10/17/2024 at 11:30 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: 10/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/18/2024
Section Cited
CCR
85076(d)(1)

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85076 Food Service (d) The licensee shall meet the following food supply…(1) Supplies of …fresh perishable foods for a minimum of two days shall be maintained on the premises.
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The Administrator will send a snapshot of perishable food items that were purchased.
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During LPA's tour, LPA observed there was not a two day supply of perishable food items. This poses a potential health, safety, or personal rights risk to clients in care.
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Type B
10/21/2024
Section Cited
CCR80070(b)(8)

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80070 Client Records (b) Each record must contain information including...(8) medical assessment. This is evidenced by:
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The Licensee will obtain the document and call LPA Spaeth upon receipt.
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LPA Spaeth observed the Physician's Report was not included in the client file. 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: 10/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2024


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Document Has Been Signed on 10/17/2024 03:23 PM - It Cannot Be Edited


Created By: Melissa Spaeth On 10/17/2024 at 01:16 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: 10/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/21/2024
Section Cited
CCR
80065(i)

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80065 Personnel Requirements (i) Prior to employment…all employees…subject to a criminal record review shall: (2) request a transfer of a criminal record clearance …This is evidenced by:
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The Administrator will contact Guardian to ensure S1 is associated to the facility. The Administrator will send proof to LPA Spaeth via email.
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The Administrator failed to ensure a staff member has been associated to the facility. 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: 10/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2024


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