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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294224
Report Date: 11/14/2024
Date Signed: 11/14/2024 12:06:41 PM

Document Has Been Signed on 11/14/2024 12:06 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:CAMPBELL VILLAGEFACILITY NUMBER:
435294224
ADMINISTRATOR/
DIRECTOR:
DE OCAMPO, GERALYNFACILITY TYPE:
740
ADDRESS:290 N. SAN TOMAS AQUINO ROADTELEPHONE:
(408) 378-2535
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY: 90TOTAL ENROLLED CHILDREN: 0CENSUS: 62DATE:
11/14/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Administrator, Geralyn de OcampoTIME VISIT/
INSPECTION COMPLETED:
12:05 PM
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Licensing Program Analysts (LPAs) Marcella Tarin and Kenneth Madrigal conducted an unannounced case management visit regarding an incident report alleging sexual abuse that was submitted to the Department on 11/13/2024. LPAs met with Administrator, Geralyn de Ocampo.

On 11/13/2024, the Department received an incident report stating on 11/12/2024, that someone touched resident R1's breast while watching TV. R1 was observed by staff to be confused and disoriented during this incident and R1 could not state who touched him/her, or state the time the incident occurred.

On 11/14/2024, LPA's interviewed ADM. ADM stated R1 moved into the facility on 10/1/2024 and resides in Assisted Living. ADM states that she was informed of the incident by another care giver on the morning of 11/12/2024. AMD states that R1 started to become disoriented and confused prior to the alleged abuse on 11/11/2024. ADM states that this is the first time R1 has alleged sexual abuse. ADM states the facility is collaborating with R1's family and case manager to reassess R1's condition.

LPAs interviewed staff. Staff S1 stated R1 is independent and enjoy doing exercises. S1 states she observed R1 disoriented and confused prior to the alleged abuse on 11/12/2024. S1 states on 11/10/2024, R1 was confused, having hallucinations and was refusing to participate in activities. S1 states she notified R1's nurse about the increase in confusion and hallucinations.

Based on record review, R1 has neurocognitive impairment and mental health impairment.

LPAs requested documentation to include: R1's needs/service plan, R1's physician's report, staffing roster for 11/11/2024, staff in-service training, and resident roster.

No deficiencies were cited today per California Code of Regulations, Title 22. This report was reviewed with Administrator, Geralyn de Ocampo and a copy of the report was provided.
Jin JackieTELEPHONE: (714) 319-3786
Marcella TarinTELEPHONE: (714) 328-5152
DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
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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