435294224-3-3-2022-26-AS-KHOS-CCSM8H-20220323092312

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435294224
Report Date: 03/03/2022
Date Signed: 03/03/2022 02:46:41 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/25/2022 and conducted by Evaluator Ryker Heberle

COMPLAINT CONTROL NUMBER: 26-AS-20220225090239

FACILITY NAME:	CAMPBELL VILLAGE		FACILITY NUMBER:	435294224
ADMINISTRATOR:	STAMM, ANELLI		FACILITY TYPE:	740
ADDRESS:	290 N. SAN TOMAS AQUINO ROAD		TELEPHONE:	(408) 378-2535
CITY:	CAMPBELL	STATE: CA	ZIP CODE:	95008
CAPACITY:	90	CENSUS: 62	DATE:	03/03/2022
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Geralyn de Ocampo		TIME COMPLETED:	02:50 PM

ALLEGATION(S):

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Facility does not have a signal system for residents

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ryker Heberle conducted an unannounced visit to open a complaint investigation regarding the above allegation. LPA met with Administrator Geralyn de Ocampo (Admin).

LPA interviewed 1 staff member and 1 resident. During interview with Admin, Admin stated that she was aware of resident call pendants not operating as intended in 5 rooms of the facility. Admin stated that the issues with the call pendants have persisted for a couple of months, but could not determine an exact date when the issues began. Admin stated that they have been in contact with the call pendant vendor, and have purchased the parts to repair the system. Facility does not have a current estimated time of arrival on the new parts.

Continued on 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20220225090239

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 VILLAGE	FACILITY NUMBER: 435294224
	VISIT DATE: 03/03/2022

NARRATIVE

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Admin indicated that while the call pendants do not contact staff radios, they do successfully ping the alert system on the front desk computer. LPA and Admin toured the area where call pendants do not work. LPA asked a resident (R1) to press their call pendant. LPA observed no radios receive the alert, despite Admin holding one.

LPA asked R1 if he/she had ever been inconvenienced or effected by the call pendants not working in the area. R1 stated that at one point, he/she had fallen in his/her room and had trouble getting up. R1 pressed the call pendant for assistance, but nobody ever arrived to help him/her up. R1 stated that this was how he/she learned that the call button doesn't work in his/her room. R1 stated that the pendant itself works, as it will go off successfully in the activities area, it just doesn't work in his/her room and the area outside of it.

LPA returned to the front desk to observed whether or not pendant presses successfully alert the computer. 1 out of 2 pendant presses were observed to alert the computer system. LPA observed 3 pendant presses accurately be reported in the call log from areas outside the dead zone. No radios were heard to have received the alert. Review of facility receipts with vendor confirm that the facility has purchased the parts to repair the system. Review of facility call logs do not indicate any calls having reached the system from the affected area.

The Department has conducted an investigation of the above allegation. Based on LPA observation, resident/staff interviews, and records reviewed, the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED. Deficiencies are being cited. See LIC 9099-D.

Exit interview conducted with Administrative Assistant Maria Perlas, Administrator Geralyn de Ocampo had to leave during inspection and gave Maria Perlas permission to sign on her behalf. A copy of this report, along with the facility's appeals rights were provided

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20220225090239

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 VILLAGE	FACILITY NUMBER: 435294224
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/03/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/04/2022 Section Cited CCR 87303(i)(1)(A)	1 2 3 4 5 6 7	87303 - Maintenance and Operation - (i) Facilities shall have signal systems which shall meet the following criteria ... (A) Operate from each resident's living unit. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee to submit written plan for signal system repair, temporary substitution, and retraining of facility staff on facility signal sytem operation.
	8 9 10 11 12 13 14	Based on LPA observation, interviews, and records review, 5 rooms in the facility have had a non operational signal system for more than 2 months. This poses an immediate risk to the personal rights of residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022

LIC9099 (FAS) - (06/04)

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