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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191221067
Report Date: 08/09/2024
Date Signed: 09/19/2024 11:10:04 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/03/2024 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20240403084551
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: 5DATE:
08/09/2024
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Felix CamposTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff abandoned resident at the hospital.
Staff did not provide adequate supervision resulting in resident wandering away from the facility.
INVESTIGATION FINDINGS:
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This is an amended copy of the report previously issued on 8/09/2024. This report supersedes reports previously issued. The findings for this complaint remain the same.

On 8/09/2024 Licensing Program Analyst (LPA) Melissa Spaeth conducted a subsequent complaint investigation at the above facility to address the following allegation(s). LPA Spaeth was met by the Administrator Felix Campos. LPA explained the purpose of this visit was to present findings.

LPA conducted a physical tour at 12:00 pm until 12:15 pm. The investigation consisted of the following: On 4/03/2024 LPA Spaeth initiated a complaint investigation for the allegation(s) listed above. LPA Spaeth received the resident roster.

Regarding the allegation: Staff abandoned the resident at the hospital: it’s being alleged that a client (C1) had been hospitalized and was to be discharged on 4/02/2024. However, C1 remained at the hospital because the Licensee was unreachable.

Continued on 9099-C

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 31-AS-20240403084551
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 191221067
VISIT DATE: 08/09/2024
NARRATIVE
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LPA Spaeth interviewed the Licensee today on 8/09/2024 at 1:27 pm. The Licensee stated on the morning of 3/25/2024, C1 had informed the Licensee they were leaving the facility to visit their mother. The Licensee stated C1’s mother lives seven blocks from the facility and C1 visited with their mother every day. The Licensee was informed the Sheriff's Department was called because C1 was missing from their mother’s home. Licensee denied receiving a phone call on or about 4/03/2024 from the hospital stating C1 was going to be released. The Licensee stated they received a voicemail message after 4/03/2024 stating C1 would not be returning to the facility and would be moving to another location. LPA Spaeth attempted to make contact on 4/09/2024, 4/24/2024 and 5/09/2024 to confirm C1’s new location but was unable. LPA Spaeth interviewed clients C2 - C6. C2 and C3 stated they witnessed C1 telling the Licensee they were leaving the facility to visit their mother. LPA was unable to interview C1. Based upon LPA’s interviews, the allegation is unsubstantiated.

Regarding the allegation: Staff did not provide adequate supervision resulting in a resident wandering away from the facility: it’s being alleged that on 3/25/2024 the client (C1) AWOL’d from the facility. The Licensee stated they relieved the night staff every morning at 7:30 am and prepared the residents’ breakfast. C2 – C6 confirmed the Licensee was at the facility when they woke up the morning of 3/26/2024. C2 – C3 confirmed they heard C1 stated to the Licensee they were leaving the facility to visit their mother. LPA was unable to interview C1 and to review C1’s records. Based upon the interviews of the residents and the Licensee, the allegation is unsubstantiated.

Exit interview conducted, and a copy of the report was given.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2