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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294224
Report Date: 02/27/2025
Date Signed: 02/27/2025 11:50:42 AM

Document Has Been Signed on 02/27/2025 11:50 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: 90CENSUS: 70DATE:
02/27/2025
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Administrator Geralyn De OcampoTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced Case Management to conduct a Non-Compliance Plan Quarterly Visit and met with Administrator Geralyn De Ocampo.

The purpose of the visit is to ensure the facility is adhering to the Compliance Plan submitted to Community Care Licensing (CCL) after an informal meeting held on October 22, 2024.

ADM tested the delayed egress door alarms, which were functional. LPA toured the facility inside and out. LPA did not observe any obstructions in the passageways.

LPA reviewed staff training such as, but not limited to: Monitoring residents with wandering behavior, elopement risk, signal system operation, completed on November 12, 2024. LPA also reviewed In-service training on how to operate egress doors/ ensuring passageways are free of obstructions, completed on November 11, 2024. LPA also reviewed staff training by ANX hospice, regarding Dementia and behaviors, completed on January 31, 2025.

LPA reviewed facility door check log, which is used to check doors are working properly and free from any obstructions in both memory care and assisted living.

LPA received a copy of the Operational Compliance Plan.

No deficiencies cited per California Code of Regulations, Title 22. This report was reviewed with Administrator Geralyn De Ocampo and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 02/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/27/2025
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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