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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200153
Report Date: 11/07/2024
Date Signed: 11/07/2024 06:20:16 PM

Document Has Been Signed on 11/07/2024 06:20 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/
DIRECTOR:		OCAMPO, CARLITO & RAQUELFACILITY TYPE:
735
ADDRESS:1511 PADRES COURTTELEPHONE:
(408) 295-3094
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY: 6CENSUS: 5DATE:
11/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:35 PM
MET WITH:Carlito OcampoTIME VISIT/
INSPECTION COMPLETED:
06:30 PM
NARRATIVE
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Licensing Program Analyst (LPAs) Marcela Yanez and Manuel Monter conducted an unannounced annual inspection visit, and met with Carlito Ocampo . During the visit, LPA observed 5 residents and 3 staff. LPA explained the purpose of the visit.

LPA toured the facility inside out with S1 which included the Living room, kitchen, dining room, 1 restroom and 3 residents bedrooms. The staff area of the facility was also inspected. The 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 storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 76 degrees F, and hot water temperature was measured at 135 degrees F in resident bathroom across from Resident bedroom #1. ADM stated he doesn't know why it was high. ADM stated it was set at "A". ADM stated the staff need to low the water after washing the blankets. LPA advised ADM that water temperature needs to be between 105 degrees F and 120 Degrees F for the safety of the residence in care. ADM agreed and understood.

Fire extinguisher was serviced in 04/15/2024. 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 08/13/2024.

LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA conducted interviews with 1 staff and 2 residents.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2024
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 4
Document Has Been Signed on 11/07/2024 06:20 PM - It Cannot Be Edited


Created By: Marcela Yanez On 11/07/2024 at 05:08 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: 11/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, 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 observation, and LPA measurement, the licensee did not comply with the section cited above. LPA measured the hot water temperature in bathroom across resident bedroom #2 at 135.0 degrees F. ADM stated he doesn't know why it was high. ADM stated it was set at "A". ADM stated the staff need to lower the water after washing the blankets. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/08/2024
Plan of Correction
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Licensee stated he will keep the water temperature between 105 degrees F and 120 degrees F. and will submit a log of week am and pm check and a template of monthly log.
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:Marcela Yanez
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 11/07/2024 06:20 PM - It Cannot Be Edited


Created By: Marcela Yanez On 11/07/2024 at 05:08 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: 11/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(b)(14)
Client Records
(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 the licensee did not comply with the section cited above. LPAs reviewed P&I records for 5 residents. While reviewing the residents P&I records LPAs discovered discrepancies. Resident R1, R3, & R5 had a surplus. R2 had a deficit of $7.95. Staff S1 stated he/she did not remember what the resident spent that amount on. LPAs were not provided with a receipt for that expense. this posed a potential personal rights risk to persons in care.
POC Due Date: 11/14/2024
Plan of Correction
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Licensee will submit a written plan of action how he will ensure resident P&I records are complete and accurate.
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:Marcela Yanez
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2024


LIC809 (FAS) - (06/04)
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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 #2
FACILITY NUMBER: 435200153
VISIT DATE: 11/07/2024
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LPAs reviewed P&I records for 5 residents. While reviewing the residents P&I records LPAs discovered discrepancies. Resident R1 had a surplus of .40 Cents. Resident R2 had a deficit of $7.95. Staff S1 stated he/she did not remember what the resident spent that amount on. LPAs were not provided with a receipt for that expense. Resident R3 had a surplus of .10 cents. Resident R5 had a surplus $7.81.

As a result, the department issued an immediate civil penalty of $500 for a repeat violation for the following deficiencies:
Hot water temperature which was cited previously on 11/21/2023
Resident P&I records (Cash Resources) cited previously on 11/21/2023

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D.
This report was reviewed with Administrator Carlito Ocampo and a copy of the report was provided. Appeal Rights was provided.

End of Report
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC809 (FAS) - (06/04)
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