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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294224
Report Date: 10/12/2021
Date Signed: 10/13/2021 08:45:22 AM

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:CAMPBELL VILLAGEFACILITY NUMBER:
435294224
ADMINISTRATOR:STAMM, ANELLIFACILITY TYPE:
740
ADDRESS:290 N. SAN TOMAS AQUINO ROADTELEPHONE:
(408) 378-2535
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY:90CENSUS: 57DATE:
10/12/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:32 PM
MET WITH:Geralyn de OcampoTIME COMPLETED:
02:55 PM
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 10/12/2021 at 01:32pm. LPA met with facility Administrator Geralyn de Ocampo (Admin).

LPA toured the facility, including living room, kitchen, dining room, laundry room, 6 bedrooms, 2 public bathrooms, back patio, front yard, salon, activities room, dining room, and kitchen. All staff members observed to be wearing masks. Admin confirmed that all staff and residents have been vaccinated.

Facility Mitigation plan has already been submitted. No prohibited items noted in resident rooms. All emergency exits noted to be clear of obstruction. All rooms in facility noted to be clean and well maintained. Hand sanitizers, soap, and paper supplies were observed to be available. At least 2 days' supply of perishable food and at least 1 week's supply of non-perishable food was observed on the premises. Fire extinguishers observed to be inspected in February of 2021.

Facility observed to have designated entry point. Staff took LPA's temperature and screened for symptoms. 30 day supply of PPE observed. All restrooms stocked with paper towels. Water temperature observed to be 111.7 *F. Hand washing signs observed in all bathrooms. All bathrooms had garbage cans with foot operated lid. Social distancing signs observed to be posted in all public areas. The facility is currently accepting visitors inside the facility, including residents' bedrooms. The facility has reached a 99% COVID-19 vaccination rate for staff and 99% for residents.

No deficiencies cited during today's visit. This report was reviewed with Administrator Geralyn de Ocampo and a copy of the signed report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021
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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