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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200153
Report Date: 05/20/2022
Date Signed: 05/20/2022 11:17:20 AM

Document Has Been Signed on 05/20/2022 11:17 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
CCLD Regional Office,
, CA
FACILITY NAME:OCAMPO RCH #2FACILITY NUMBER:
435200153
ADMINISTRATOR:OCAMPO, CARLITO & RAQUELFACILITY TYPE:
735
ADDRESS:1511 PADRES COURTTELEPHONE:
(408) 295-3094
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY: 6CENSUS: 4DATE:
05/20/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Carlito OcampoTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Marybeth Donovan conducted a Technical Assist (TA) Visit via FaceTime with Carlito Ocampo Administrator, Helen Shi RN, Program Clinical Consultant, and Sarah Yip Licensing Program Manager to provide technical assistance to prevent and mitigate the spread of COVID 19 in the facility. LPA conducted a virtual tour of the facility.

During today's TA-Visit, recommendations were discussed as follows:

1. Post updated Visitor Policy, Mask Requirements and staff Donning and Doffing posters at the central entry point to the facility
2. Place PPEs outside of front entry for staff use
3. Staff to wear full PPEs and encourage residents to wear N95 masks in common areas
4. Use paper towels instead of cloth towels
5. Keep bathroom and bedroom doors closed during quarantine duration

LPA will forward video of PPE Donning and Doffing and Posters. RO will provide additional supply of PPEs and antigen test kits.

Report reviewed with Carlito Ocampo and a copy emailed for signature.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Marybeth Donovan
LICENSING EVALUATOR SIGNATURE: DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2022
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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