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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435200258
Report Date: 03/28/2024
Date Signed: 03/28/2024 03:37:59 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/19/2022 and conducted by Evaluator Chihhsien Chang
COMPLAINT CONTROL NUMBER: 26-AS-20220419171827
FACILITY NAME:OCAMPO RESIDENTIAL CARE HOME #3FACILITY NUMBER:
435200258
ADMINISTRATOR:OCAMPO, CARLITO & RAQUELFACILITY TYPE:
735
ADDRESS:430 ROYALE PARK DRIVETELEPHONE:
(408) 578-9626
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY:6CENSUS: 6DATE:
03/28/2024
UNANNOUNCEDTIME BEGAN:
01:39 PM
MET WITH:Carlito OcampoTIME COMPLETED:
02:11 PM
ALLEGATION(S):
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Staff hit resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation finding and met with Administrator (ADM) Carlito Ocampo.

On 4/19/2022, the Department received a complaint with the allegation that the facility staff hit resident.

On 4/28/2022, an initial complaint investigation visit was conducted. 3 staff and 3 resident were interviewed. Resident physician reports, Appraisal Needs and Services Plans, admission agreement, incident report, and staff personal file were obtained.

On 1/26/2023, LPA conducted an investigation visit and interviewed 4 staff and 4 residents.

Continue on LIC9099-C. Page 1 of 2.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 26-AS-20220419171827
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: OCAMPO RESIDENTIAL CARE HOME #3
FACILITY NUMBER: 435200258
VISIT DATE: 03/28/2024
NARRATIVE
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Staff hit resident:
On 3/24/2022, resident R1 reported that a staff hit him/her. On the same day, R1 was assessed but there was no visible injury on R1's body.

On 4/28/2022, LPA interviewed Administrator (ADM) Carlito Ocampo. ADM stated resident R1 reported to the day program that R1 was hit by a staff and the day program reported to police department. ADM stated police officers came to facility to investigate.

ADM stated the suspect staff S1 was helping a resident R2 for shower and R1 also used the toilet in the bathroom. ADM stated S1 tried to get the shampoo for R2 and accidentally toughed R1. ADM stated R1 did not report any pain or staff abuse to ADM.

On the same day, LPA interviewed 3 staff (S2 - S4). 3 out of 3 staff stated they did not see facility staff hit a resident.

On 1/26/2023, LPA interviewed R1. R1 denied the facility staff hit him/her. LPA interviewed another two residents (R2 - R3). 2 out of 2 residents denied that the facility staff hit residents.

LPA interviewed S1. S1 denied he/she hit resident R1. LPA interviewed two staff (S5, S6). 2 out of 2 staff stated they did not see or hear any staff hit or abused resident.

Based on record reviewed and interviews, there is no evidence indicating S1 hit or physically abused R1.

The Department has investigated the above allegation. Based on interviews and records reviewed, the department has found the above allegations are unsubstantiated. An unsubstantiated finding indicates that although the allegation may have happened and/or is valid, there is not a preponderance of evidence to show the alleged violations did or did not occur.

No citation was noted today. Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of the report was provided to ADM.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2