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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191221067
Report Date: 01/29/2025
Date Signed: 01/29/2025 02:33:55 PM

Document Has Been Signed on 01/29/2025 02:33 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:		FELIX I. CAMPOS JR.FACILITY TYPE:
735
ADDRESS:226 E. AVENUE Q-3TELEPHONE:
(661) 274-9509
CITY:PALMDALESTATE: CAZIP CODE:
93550
CAPACITY: 6CENSUS: 5DATE:
01/29/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Felix CamposTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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Lisensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced visit and when exiting the car was greeted by the Administrator, Felix Campos. LPA Spaeth stated the purpose of the visit was to conduct a tour of the facility.

Upon entering the facility, LPA observed two residents were in the facility and there were no staff members present. The Administrator stated the staff member was in their room. At 11:05 am, the Licensee went to the staff door and knocked several times; however, no one responded. Fifteen minutes later the Administrator and the staff member approached LPA stating the staff member was present in their room. LPA Spaeth explained staff members shall be able to ensure the safety and well being of the clients at all times.

Since the staff member did not respond to the Administrator's request to exit the staff room, the following deficiency is 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: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2025
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 01/29/2025 02:33 PM - It Cannot Be Edited


Created By: Melissa Spaeth On 01/29/2025 at 11:41 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: 01/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/31/2025
Section Cited
CCR
80065(a)

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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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The Administrator will send a weekly work schedule to LPA Spaeth via email starting February 3, 2025 until March 3, 2025.
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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: 01/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2025


LIC809 (FAS) - (06/04)
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