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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200501
Report Date: 11/28/2023
Date Signed: 11/28/2023 04:41:18 PM

Document Has Been Signed on 11/28/2023 04:41 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:
11/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Carlito Ocampo, ADMTIME COMPLETED:
01:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) conducted an unannounced annual inspection today and met with Administrator (ADM) Carlito Ocampo.

LPA observed 4 staff in the facility including administrator. LPA reviewed 5 client files and 5 staff files.

LPA toured the facility inside out with ADM. Living room, family room, dinning room, laundry room, kitchen and restrooms were inspected. There was no non skid pad in the shower area of the bathroom. 1 staff room and 3 resident shared rooms were observed in the facility. Medication closet, knives closet were observed locked. Detergent was observed unlocked by the sink in the kitchen. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Room temperature was at 70 degree F, and hot water temperature was at 106 degree F. The temperature of the refrigerator was measured at 40 degree F, and the temperature of the freezer was measured at 0 degree F. Two screens of windows were observed not in good repair.

Fire extinguisher was observed serviced on 04/12/2023. The facility is equipped with smoke and carbon monoxide detectors. Smoke dictators were tested and were working fine. Front yard and back yard were inspected. No obstruction was observed to block the walkway.

LPA reviewed the facility records, it shows the facility had emergency and fire drill on 11/02/2023. Three caregivers' first aid training certificate were observed expired.

Deficiencies were 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: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/28/2023
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 11/28/2023 04:41 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 11/28/2023 at 12:52 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 RESIDENTIAL CARE HOME #4
FACILITY NUMBER: 435200501

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above that detergent was observed by the sink in kitchen unlocked which poses/posed a potential health, safety risk to persons in care.
POC Due Date: 12/05/2023
Plan of Correction
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Licensee stated to submit a plan of correction by the POC due date to put the detergent in the cabinet under the sink in the kitchen and to add a new lock on it.
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above in that two screens of windows were observed not in good repair which poses/posed a potential health, safety risk to persons in care.
POC Due Date: 12/05/2023
Plan of Correction
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Licensee stated to submit a plan of correction by the POC due date to fix the screens of windows.
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:Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 11/28/2023 04:41 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 11/28/2023 at 12:52 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 RESIDENTIAL CARE HOME #4
FACILITY NUMBER: 435200501

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(3)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (3) All toilets, handwashing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation, the licensee did not comply with the section cited above in that there was no non skid pad in the shower area of the bathroom which poses/posed a potential health, safety risk to persons in care.
POC Due Date: 12/05/2023
Plan of Correction
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Licensee stated to submit a plan of correction by the POC due date to place non skid pads in the shower area of the bathroom.
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

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 in that three caregivers' first aid training certificate were observed expired which poses/posed a potential health, safety risk to persons in care.
POC Due Date: 12/05/2023
Plan of Correction
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Licensee stated to submit a plan of correction by the POC due date to have the three caregivers to obtain valid first aid training certificate.
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:Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2023


LIC809 (FAS) - (06/04)
Page: 3 of 3