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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200501
Report Date: 11/19/2024
Date Signed: 11/19/2024 04:50:39 PM

Document Has Been Signed on 11/19/2024 04:50 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 RESIDENTIAL CARE HOME #4FACILITY NUMBER:
435200501
ADMINISTRATOR/
DIRECTOR:
OCAMPO, RAQUELFACILITY TYPE:
735
ADDRESS:4012 VICTORIA PARK DRIVETELEPHONE:
(408) 225-7155
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY: 6CENSUS: 5DATE:
11/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:36 PM
MET WITH:Carlito Ocampo, ADMTIME VISIT/
INSPECTION COMPLETED:
04:37 PM
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Licensing Program Analyst (LPA) conducted an unannounced annual inspection today and met with Administrator (ADM) Carlito Ocampo.

LPA observed 3 staff and 5 residents in the facility. LPA reviewed 3 client files and 2 staff files. License, personal rights posters were observed in the facility. Administrator certificate was observed expired. ADM showed his/her ADM certificate is in active list on the website.

LPA toured the facility inside out with ADM. Living room, family room, dinning room, laundry room, kitchen, garage, and restrooms were inspected. 1 staff room and 3 resident shared rooms were observed in the facility. Medication closet, knives closet, and Detergent closet were observed locked. 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 108 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. First aid box, flash lights were observed in the facility.

Fire extinguisher was observed serviced on 04/15/2024. The facility is equipped with smoke and carbon monoxide detectors. Smoke detectors 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 11/05/2024.

No citation 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: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2024
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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