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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200153
Report Date: 11/21/2023
Date Signed: 11/21/2023 04:15:52 PM

Document Has Been Signed on 11/21/2023 04:15 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: 6DATE:
11/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator OcampoTIME COMPLETED:
04:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator (ADM) Ocampo. During visit, LPA observed 6 residents and 3 staff.

LPA toured the facility inside out with ADM which included; the Living room, kitchen, dining room, 2 restrooms and 3 residents bedrooms. The staff area of the facility was also inspected. Front yard and backyard were inspected. There was no obstruction to block the walkways.

Two day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication closet, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 70 degrees F, and hot water temperature was measured at 130 degrees F in both resident bathrooms.

Fire extinguisher was serviced in April 18, 2023. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on November 2, 2023.

LPA conducted interviews with 3 staff (S1 to S3) and 3 residents (R1-R3). LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA reviewed 3 resident P&I records. While reviewing R1's records ADM and LPA discovered R1 had $3.00 dollars that were not accounted for in his/her P&I records. ADM stated R1 might have given the staff the change from previous outings, the staff would proceed to put the change in his/her P&I packet without accounting it in his/her records over a period of time.

Deficiencies are being cited during visit. This report was reviewed with Administrator Ocampo and a copy of the signed report was provided. Appeal rights were also provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2023
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 11/21/2023 04:15 PM - It Cannot Be Edited


Created By: Manuel Monter On 11/21/2023 at 03:52 PM
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 #2
FACILITY NUMBER: 435200153

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2023

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's measurement, the licensee did not comply with the section cited. LPA measured the water temperature, with ADM observing, in the facility's hallway bathroom. The water temperature was observed measuring at 130 degrees F. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2023
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 maintenance 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:Romeo Manzano
LICENSING EVALUATOR NAME:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 11/21/2023 04:15 PM - It Cannot Be Edited


Created By: Manuel Monter On 11/21/2023 at 04:00 PM
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 #2
FACILITY NUMBER: 435200153

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(b)(14)
(b) Each record must contain information including, but not limited to, the following: (14) An account of the client's cash resources, personal property, and valuables entrusted as specified in Section 80026.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on Record review, While LPA and ADM reviewed R1's P&I records, it was discovered that resident R1 did not have approximately $3.00 dollars recorded in his/her record. ADM stated he believes R1 might come home and give staff the change from his/her outing and the staff did not account those funds to R1's P&I records. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/28/2023
Plan of Correction
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ADM stated she will send plan of action on how she will keep the cash resources records up to date and correct. ADM stated she will send plan of action to LPA by POC date, 11/28/2023
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:Romeo Manzano
LICENSING EVALUATOR NAME:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2023


LIC809 (FAS) - (06/04)
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