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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294224
Report Date: 03/19/2025
Date Signed: 03/19/2025 03:30:06 PM

Document Has Been Signed on 03/19/2025 03:30 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: 71DATE:
03/19/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:55 PM
MET WITH:Administrator Geralyn De OcampoTIME VISIT/
INSPECTION COMPLETED:
03:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter arrived unannounced to deliver the results of 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 Geralyn De Ocampo.

While investigating the complaint 26-AS-20240529150017, LPA reviewed R1’s Appraisal/Needs & Services Plan (ANS), dated May 11, 2023, signed on December 15, 2023. The ANS states R1 has a neurocognitive disorder. The ANS states R1 is a fall risk. R1 also has a history of falls at home. R1 uses a walker but refuses to use it at times. The ANS states R1 also wanders at times. Under Objective/Plan, the ANS states to observe fall precautionary measures: provide a well lighted room at all times, maintain a clutter free environment, remind R1 to seek staff’s assistance at all times, monitor for any changes in functioning skills.

ADM stated the facility did have a plan to address the falls. ADM stated the facility plan to address R1’s behaviors included the following; ADM stated they put in a bed alarm in R1’s bed. ADM stated she instructed staff to supervise R1 and ensure that R1 is assisted when walking, due to his fall risk. ADM stated the night shift was instructed to ensure to wait outside R1’s bedroom door to ensure that R1 had fallen asleep, because R1 will get up at night and wander. ADM stated staff was instructed to keep R1 within their line of sight. LPA asked if ADM updated the care plan to reflect these changes she noted to LPA. ADM stated she did not update the care plan.

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: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2025
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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Document Has Been Signed on 03/19/2025 03:30 PM - 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: 03/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/26/2025
Section Cited
CCR
87463(a)

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87463 Reappraisals (a) The pre-admission appraisal… shall be updated in writing as frequently as necessary …to note significant changes in condition…and to keep the appraisal accurate…

This requirement was not met as evidence by:
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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, March 26, 2025
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Based on records reviewed and interviews conducted, the changes facility ADM stated she implemented to address R1’s falls were not reflected on R1’s Needs and Services Plan. ADM acknowledged she did not update the care plan. This poses a potential health, safety or personal rights risk to persons in care.
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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: 03/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2025

LIC809 (FAS) - (06/04)
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