<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294224
Report Date: 02/13/2025
Date Signed: 02/13/2025 11:36:32 AM

Document Has Been Signed on 02/13/2025 11:36 AM - 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: 67DATE:
02/13/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Administrator Geralyn De OcampoTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Manuel Monter and Kenneth Madrigal arrived unannounced visit to open a complaint investigation. During the complaint investigation, a case management deficiencies visit was conducted due to violations discovered during the investigation process. LPA met with Administrator Administrator Geralyn De Ocampo

While investigating the complaint 26-AS-20250212162218, LPA reviewed resident R1's facility binder. LPA observed the residents Appraisal form, LIC603A, did not have the residents name or age filled out. Furthermore this form had several sections with missing information's such as: Health, physical disabilities, mental condition, health history & social factors.

ADM stated the resident was supposed to fill out this form, but did not. LPA explained to ADM, the pre-admission appraisal needs to be filled out by the facility to determine the prospective resident's suitability for admission and that residents potential needs/services they would require.

ADM stated she did do the residents appraisal, but only forgot to fill out the first page of the form.

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Administrator Geralyn De Ocampo and a copy of the report and appeal rights were provided.
Romeo ManzanoTELEPHONE: (408) 388-2297
Manuel MonterTELEPHONE: (408) 324-2112
DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 02/13/2025 11:36 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 VILLAGE
FACILITY NUMBER: 435294224

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/20/2025
Section Cited
CCR
87457(c)

1
2
3
4
5
6
7
87457 Pre-Admission Appraisal (c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed ... their individual service needs ... specified in Section 87455, Acceptance and Retention Limitations. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
ADM stated she will send a letter of understanding regarding the regulation. ADM stated she will send the plan of correction to LPA by POC date, February 20, 2025.
8
9
10
11
12
13
14
Based on record review, the residents pre admission appraisal was not filled out and had missing information such as Residents Name & Age, Health, physical disabilities, mental condition, health history & social factors. This poses a potential health, safety or personal rights risk to persons 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.
Romeo ManzanoTELEPHONE: (408) 388-2297
Manuel MonterTELEPHONE: (408) 324-2112

DATE: 02/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2025

LIC809 (FAS) - (06/04)
Page: 2 of 2