435294224-3-19-2025-26-AS-KHOS-DF4LP8-20250325085532

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435294224
Report Date: 03/19/2025
Date Signed: 03/19/2025 03:30:49 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 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
05/29/2024 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20240529150017

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: 71	DATE:	03/19/2025
		UNANNOUNCED	TIME BEGAN:	02:55 PM
MET WITH:	Administrator Geralyn De Ocampo.		TIME COMPLETED:	03:35 PM

ALLEGATION(S):

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Facility is not providing proper care and supervision resulting to multiple injuries sustained by resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegations. LPA met with Administrator Geralyn De Ocampo.

On May 29, 2024, the Department received a complaint alleging facility is not providing proper care and supervision resulting to multiple injuries sustained by resident.

On June 6, 2024 and February 27, 2025, LPA Monter interviewed facility ADM. ADM stated the family did inform the facility about R1’s previous falls at the home. ADM stated the facility was already aware that R1 was a fall risk. ADM stated R1 needs assistance with walking, Because R1 has unstable gait. ADM stated staff was aware of R1’s that R1 has an unsteady gait and that they need to assist R1 if he/she tries to walk to prevent falls. ADM stated the falls are just accidents that happen. ADM stated that the staff is watching him/her. ADM stated the facility also put a bed alarm on R1’s bed to ensure staff was aware if R1 got out of bed.
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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	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.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 26-AS-20240529150017

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 03/19/2025

NARRATIVE

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LPA Monter interviewed staff S1-S8. S1 stated if R1 is agitated, will walk by himself/herself. S1 stated the care givers are there and will assist the R1 whenever R1 tries to walk. S1 stated that at night, R1 will try to get up and go to the bathroom, in his/her bedroom. S1 stated R1 will also sometimes go out of his/her room. S1 stated R1’s bed has an alarm that will notify staff if R1 gets out of bed.

S2 stated R1 has an issue with his/her knee and loses balance. S2 stated R1 needs assistance in walking. S2 stated staff will go with R1 when R1 walks. S3 stated R1 needs assistance walking. S3 stated R1 has an unsteady gait and uses a wheelchair or walker that he/she doesn’t like to use.

S4 stated R1 is unstable, so he/she assists R1 to ensure he/she doesn’t fall. S4 stated staff are supposed to watch R1 because he/she likes to try to walk by him/herself. S4 stated staff are supposed to assist R1 when he/she walks or a hand to keep R1 safe. S5 stated R1 is a rebellious resident. S5 stated R1 will listen sometimes and will not listen other times. S5 stated when he/she sees R1 walk, he/she will offer R1 the wheelchair. S6 stated R1 needs help with walking. S6 stated he/she has helped R1 walk a little. S6 stated that he/she has not had many interactions with R1.

S7 stated when R1 walks around, he/she has an unsteady gait. S7 stated R1 holds onto the side rail when walking. S7 stated staff are supposed to assist R1 if he/she gets up or tries to walk. S7 stated R1 will try to get up in the middle of the night. S7 stated R1 will be put in bed and then will get up and walk around. S7 stated the night shift needs that supervision because R1 is a fall risk and likes getting up at night. S7 stated the night alarm goes off at night. S8 stated R1 can walk, but its unsteady. S8 stated they are supposed to keep an eye on R1 because he/she likes to get up on his/her own but has an unsteady gait.

On March 7 & 13, 2025, LPA Monter interviewed staff S9-S11. S9 stated staff make sure they are watching R1 during their shift. S9 stated R1 wanders and is fall risk. S10 stated R1 was able to walk a little, but shaky and not stable. S10 stated staff was supposed to help R1 when he/she walks because he/she’s a fall risk. S11 stated he/she worked the night shift but doesn’t remember working with resident R1.

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SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	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

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 26-AS-20240529150017

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 03/19/2025

NARRATIVE

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Based on a review of R1’s Physicians report, dated June 3, 2024, R1 has a neurocognitive disorder.

Based on a review of 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.

Based on a review of facility incident report, dated February 29, 2023, R1 sustained a fall on February 28, 2023 around 4:30am and was found sitting on the floor. Resident R1 returned to the facility after a few hours from the ER and had a right orbital fracture.

Based on review of facility incident Report, dated March 23, 2023, R1 sustained a fall around 10:45am, while walking. A staff member who was closest to R1 was unable to catch R1 as he/she fell.

Based on a review of facility Physician visit communication form, dated January 9, 2024. Attached to this communication was an after-visit summary form with stated “ER transfer patient with R Chest and R abdomen pain after probable fall.”

Based on a review of facility incident report, dated January 18, 2024, R1 had sustained an unwitnessed fall around 5:30am on January 13, 2024. Resident R1 returned to the facility to the facility late in the afternoon.

Based on a review of facility incident report, dated February 7, 2024, states at 7:30 R1 complained of knee pain. Staff gave medication and put R1 to bed. Staff walked along the hallway when he/she heard a crash sound. Staff saw R1 on the floor on his/her right side. R1 had no bumps or any redness, except for a bloody cheek.

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SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	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

LIC9099 (FAS) - (06/04)

Page: 4 of 4

Control Number 26-AS-20240529150017

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 03/19/2025

NARRATIVE

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Based on a review of Facility incident report, dated March 7, 2024, R1 sustained an unwitnessed fall in the dining area at 7:30pm. Staff checked R1 over and there were no cuts bumps, scrapes.

Based on a review of facility incident report, dated May 13, 2024, R1 was walking and lost balance and fell on floor, at 1:20pm. Staff checked up on R1. R1 stated he only felt pain his/her butt and a little in the back.

Based on a review of facility incident report, dated May 24, 2024, R1 had sustained unwitnessed fall on 5/24/24, inside his/her room at 5:30am. R1 was bleeding on his/her forehead. Resident R1 returned to the facility the same day, around 1pm.

Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. Although it is a fact that resident R1 sustained falls at the facility, there is not a preponderance of evidence to prove that the allegations neglect/lack of supervision did or did not occur.

Page 4 Out of 4. END OF REPORT.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	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

LIC9099 (FAS) - (06/04)

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