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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200501
Report Date: 11/16/2021
Date Signed: 11/16/2021 02:31:47 PM

Document Has Been Signed on 11/16/2021 02:31 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:OCAMPO RESIDENTIAL CARE HOME #4FACILITY NUMBER:
435200501
ADMINISTRATOR:OCAMPO, RAQUELFACILITY TYPE:
735
ADDRESS:4012 VICTORIA PARK DRIVETELEPHONE:
(408) 225-7155
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY: 6; 6CENSUS: 5DATE:
11/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Carlito Ocampo, ADMTIME COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) conducted an unannounced annual inspection today. Upon arrival, staff Crisanto Garcia (CG) took LPA's body temperature, asked infection control questionnaires, and checked LPA in guest log book. LPA observed COVID posters in the facility.

LPA toured the facility inside out with CG. Living room, dinning area, laundry room, kitchen and restrooms were inspected. All the trash cans are with covers. LPA observed 3 staff and 3 residents in facility. The other two residents were out for day program. Medication closet, knives closet, and cleaning product closet were observed locked. There are 3 resident shared rooms and one staff live in room. The beds in shared rooms were observed 6 feet apart. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient.

Fire extinguisher was observed serviced on 04/12/2021. Smoke dictators were tested and were working fine. Room temperature was observed at 70 degree F. Hot water temperature was observed at 115 degree F. Front yard and back yard were inspected. No obstruction was observed to block the walkway.

LPA reviewed LIC808 with administrator (ADM) Carlito Ocampo. ADM stated all the residents and staff are fully vaccinated and all staff and residents have the booster shots.

No deficiency or citation was noted today. Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of this report was emailed to ADM.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2021
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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