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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430707919
Report Date: 09/28/2022
Date Signed: 09/28/2022 11:40:32 AM

Document Has Been Signed on 09/28/2022 11:40 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:OCAMPO RCHFACILITY NUMBER:
430707919
ADMINISTRATOR:OCAMPO, CARLITOFACILITY TYPE:
735
ADDRESS:3084 JENKINS AVENUETELEPHONE:
(408) 267-3929
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY: 6CENSUS: 4DATE:
09/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Lucila FaylogaTIME COMPLETED:
11:41 AM
NARRATIVE
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 09/28/2022 at 10:20am. LPA met with facility staff member Lucila Fayloga. Administrator Carlito Ocampo was unable to attend the inspection, and gave staff member Lucila Fayloga permission to sign on his behalf.

LPA toured the facility, including living room, kitchen, 4 resident rooms, 2 bathrooms, garage, back patio, and backyard. Facility observed to have central entry point with hand sanitizer and thermometer. Staff members were not observed to be wearing masks. All emergency exits noted to be clear of obstruction. All rooms in facility noted to be clean and well maintained. Facility observed to have possession of 30-day supply of PPE.

Facility observed to have 2 days of perishable food and 1 weeks worth of non-perishable food. Facility temperature observed to be maintained at 69 *F. Facility water temperature measured at 130.3*F in facility bathroom and 142.1*F in kitchen sink. Facility smoke detectors tested and observed to be functioning properly. Sharps noted to be stored in locked drawers.

Facility observed to have designated entry point. Staff did not take LPA's temperature nor screened for symptoms upon entry. All bathrooms observed to have paper towels and hand washing signs posted. Trash cans observed not to have lids.

Deficiencies cited during visit. Advisory notes issued. This report reviewed with facility staff member Lucila Fayloga and a copy of the signed report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Ryker Heberle
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2022
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 09/28/2022 11:40 AM - It Cannot Be Edited


Created By: Ryker Heberle On 09/28/2022 at 11:20 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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: OCAMPO RCH
FACILITY NUMBER: 430707919

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
80088(e)(1) Furniture, Fixtures, Equipment, and Supplies - (e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in 2 out of 2 facility sinks which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2022
Plan of Correction
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Facility to adjust facility water temperature to within acceptable levels and provide proof of correction by POC due date. Facility to maintain water temperature maintance log for 1 week and provide report to licensing upon completion.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Sarah Yip
LICENSING EVALUATOR NAME:Ryker Heberle
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2022


LIC809 (FAS) - (06/04)
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