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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430707919
Report Date: 09/22/2025
Date Signed: 09/22/2025 12:29:33 PM

Document Has Been Signed on 09/22/2025 12:29 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:
09/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Angelica Ocampo - AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Maria (Mita) Partoza, conducted an unannounced required 1-year inspection visit, met with designated administrators (DADMs) Angelica Ocampo (1) and Lucila Fayloga (2). LPA stated the purpose of the visit.

The facility is licensed to serve adults 18 to 59 years old, who are ambulatory.

At 8:45 a.m. LPA was accompanied by S1 while doing inspection of the facility interior and exterior. LPA inspected the kitchen, dining, living room 3 resident bedroom, 1 staff bedroom, garage, storage shed, covered patio, backyard and exterior walkways.

LPA observed that the exterior walkways was free from obstructions, the interior walkways are free from obstructions. Knives, sharps and medications are located in the kitchen and are not easily accessible to residents in care. The residents rooms have storage that is sufficient to store residents personal belongings. The bathroom are equipped with the grab bars, and anti skid mats, personal hygiene product are available for residents to use. Chemicals, cleaning supplies and laundry products are locked and not accessible to residents in care.

The facility temperature is at 74 degree F, the refrigerator temperature is at 32 degree F, freezer temperature is at 0 degree F, hot water temperature in the resident bathroom measured at 109.7 degree F. The kitchen sink has a warning sign that states the water temperature exceeds 125 degree F.

See LIC 809C
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 RCH
FACILITY NUMBER: 430707919
VISIT DATE: 09/22/2025
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LPA observed food supply for 2 days of perishable and 7 days of non-perishable food items.

The facility is equipped with smoke and carbon monoxide alarm system, a fire extinguisher that was last inspected on 04/21/2025. LPA verified the first aid kit is complete with instruction manual.

LPA reviewed the facility file to verify quarterly fire and earthquake drill training. Based on record review, the training was last administered on 03/18/2025. DADM (2), stated that the last training was conducted in July of 2025, but was not recorded (HSC 1565 (c) - Disaster Preparedness).

LPA reviewed 3 resident record including but not limited to personal and incidental allowance(P&I), Centrally Stored Medication Record (CSMDR), physician's report, appraisal needs and services plan. LPA reviewed 3 staff record including but not limited to background clearance, certificates, and training. Resident and staff records are complete and up to date

During today's required 1-year inspection deficiency was cited based on California Code of Regulations (CCR) Title 22, Health and Safety Code (HSC) 1565 (c).

An exit interview was conducted with Designated Administrator (2) Lucila Fayloga. Designated Administrator (1) Angelica Ocampo could not stay for the exit interview due to prior commitment. A copy of the report and appeals rights was provided.

End of Report
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/22/2025 12:29 PM - It Cannot Be Edited


Created By: Maria Partoza On 09/22/2025 at 11:52 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: 09/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee/adminsitrator did not document quarterly emergency drill administered to staff and residents in a quarterly basis. The last recorded emergency disaster preparedness training was administered and recorded on 03/18/2025, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/03/2025
Plan of Correction
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DADM 2 stated that plan to correct the deficiency will update the record to reflect the July 2025 training, and will conduct evacuation disaster preparedness on 09/30/2025. DADM 2 stated that he/she will provide proof of correction to LPA by the 10/03/2025 reflecting the dates when trainings were administered to staff and residents.
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.
Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:
Maria Partoza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2025


LIC809 (FAS) - (06/04)
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