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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191221067
Report Date: 10/16/2024
Date Signed: 10/17/2024 03:25:05 PM

Substantiated


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
10/16/2024 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20241016112001
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:
10/16/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Felix CamposTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Staff did not address bedbugs in the facility
INVESTIGATION FINDINGS:
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On 10/17/2024 Licensing Program Analyst (LPA), Melissa Spaeth conducted a 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 conduct interviews and present findings.

LPA conducted a physical plant tour at 9:00 am until 9:20 am. LPA interviewed three out of the five residents at 9:20 am until 9:55 am. LPA Spaeth interviewed the Administrator at 9:55 am until 10:15 am. LPA Spaeth requested the resident roster and received the document.

Regarding the allegation: Staff did not address bed bugs in the facility. It’s being alleged the clients have bed bug bites. Three clients out of five confirmed they have seen bed bugs and had bed bug bites. C4

Continued on 9099-C
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 31-AS-20241016112001
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: 10/16/2024
NARRATIVE
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could not remember and C5 had not seen bed bugs. The Administrator stated there were bed bugs and a professional cmpany sprayed the facility on Saturday, October 12, 2024. The Administrator will forward the receipt via email to LPA Spaeth.

Based upon client and Administrator interviews, the allegation is substantiated.

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
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20241016112001
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/21/2024
Section Cited
CCR
80087(a)(1)
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80087 Buildings & Grounds (a) The facility shall be clean, safe, sanitary…(1) The licensee shall take measures to keep the facility free of flies & other insects. This requirement is not met as evidenced by:
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The Administrator will send a receipt to LPA Spaeth via email as proof the exterminator sprayed the facility.
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Based on client and Administrator interviews, the Administrator/Licensee failed to ensure the facility was free of bugs 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.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3