<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430707919
Report Date: 09/11/2024
Date Signed: 09/11/2024 05:23:40 PM

Document Has Been Signed on 09/11/2024 05:23 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:OCAMPO RCHFACILITY NUMBER:
430707919
ADMINISTRATOR/
DIRECTOR:
OCAMPO, CARLITOFACILITY TYPE:
735
ADDRESS:3084 JENKINS AVENUETELEPHONE:
(408) 267-3929
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY: 6CENSUS: 3DATE:
09/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:20 PM
MET WITH:Administrator-Carlito OcampoTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPAs) Simi Rai and Marcela Yanez conducted an unannounced Required 1 Year visit and met with Administrator (ADM) Carlito Ocampo. LPAs observed 2 staff and 2 residents at the facility since 1 resident is at work.

During visit, LPA Rai toured the inside and outside of the facility. When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. Sharps and medications were locked in secured areas. LPA observed additional food supply areas and secured areas for cleaning supplies and laundry detergents.

LPA Rai toured the resident bedrooms. 3 out of 3 resident bedrooms had available bedding, drawers, and functioning lights

The facility bathroom had available soap, paper towels, and trash cans with lids. The water temperature in the bathroom sink was 105.1 degrees F. The water temperature in the kitchen sink was 112 F.

Fire extinguisher was observed and inspected on 04/15/2024 smoke detectors and carbon monoxide detectors were in working condition. The last fire drill was on 07/31/2024 and earthquake drill on 07/30/2024.

LPA Yanez reviewed facility records for 3 staff and 3 residents. LPA Rai reviewed resident medications and central stored medication records.

No deficiencies were cited per California Code of Regulations, Title 22. Technical Violation was provided. This report was reviewed with Designated Administrator, Angel Ocampo and a copy of the report.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2