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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200153
Report Date: 12/27/2022
Date Signed: 12/27/2022 03:52:19 PM

Document Has Been Signed on 12/27/2022 03:52 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 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: DATE:
12/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Staff, Mary PineTIME COMPLETED:
04:00 PM
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On 12/27/2022 at 3:05pm, Licensing Program Analyst (LPA) Simi Rai conducted an unannounced annual required inspection and met with Staff Mary Pine. Administrator Carlito Ocampo was informed via telephone.

During visit, LPA Rai toured the facility to include the family room, living room, dining room, kitchen, 3 bedrooms, 1 staff room, 2 bathrooms, garage, and backyard. All fire exit routes were free and clear of obstruction. All staff observed wearing a face covering. LPA observed 5 clients at the facility.

Facility has a designated entry point for sign-in, symptom screening, and temperature check for all visitors and staff. Hand sanitizer made available at entry and throughout the facility. Visitation guidelines posted at the entrance. Bathrooms supplied with hygiene products, paper supplies, and hand washing sign. LPA Rai observed facility's Personal Protective Equipment (PPE) supplies. Facility has procedures to isolation and testing for COVID-19. Staff are trained on infection control. Staff are N95 fit tested. Facility staff clean and disinfect multiple times daily and as needed. The following posters observed to include wash your hands and symptoms of COVID-19.

LPA Rai observed an activity room in the Open Patio area on the facility sketch. LPA Rai spoke to ADM, and he stated the activity room has been part of the house since obtaining the license. LPA Rai notified ADM the last facility sketch provided to Department on November 17th, 1994 does not show an Activity Room. Administrator will submit new facility floor plan to LPA Rai by Wednesday, December 28, 2022.

LPA Rai observed a no visitor sign posted at the front door. Staff removed the no visitor sign during visit. LPA Rai advised of the visitation guidelines per PIN 22-28.1-ASC.

No deficiencies were cited per California Code of Regulations, Title 22.
This report was reviewed with Staff Mary Pine and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 12/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2022
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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