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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200712
Report Date: 01/19/2024
Date Signed: 01/19/2024 05:26:04 PM

Document Has Been Signed on 01/19/2024 05:26 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:CAMARGO HOMEFACILITY NUMBER:
435200712
ADMINISTRATOR:NAPOLEON FRANCISCOFACILITY TYPE:
735
ADDRESS:1911 CAMARGO DR.TELEPHONE:
(408) 941-0712
CITY:SAN JOSESTATE: CAZIP CODE:
95132
CAPACITY: 6CENSUS: 3DATE:
01/19/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:20 PM
MET WITH:Administrator Napoleon FranciscoTIME COMPLETED:
05:30 PM
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced case management visit regarding an incident report. LPA met with Administrator, Napoleon Francisco and explained the purpose of the visit.

On January 19, 2024, the Department received an incident report stating on January 18,2024, resident, R1 was found in another residents bedroom, lying down on his/her back, breathing heavily. While assisting R1, staff contacted 911. Staff then noticed R1 seemed not to be breathing anymore. The department was notified thru a subsequent incident report that R1 had passed away. The cause of death is unknown at this time

LPA requested R1's Progress Notes , R1's Identification and Emergency Information, San Andrea's Regional Center(SARC) schedule, functional capabilities, Appraisal needs and services plan, SARC IPP reports, R1's Behavioral consult/ Quarterly Report, Nutrition Assessment, LIC500.

This case management will be kept open pending investigation.

Exit interview was conducted with Administrator, Napoleon Francisco. A copy of this report was provided to Administrator, Napoleon Francisco.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 01/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/19/2024
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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