435294224-5-7-2025-26-AS-KHOS-DGMMA7-20250513092553

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435294224
Report Date: 05/07/2025
Date Signed: 05/07/2025 05:09:32 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
05/02/2025 and conducted by Evaluator Marcella Tarin

COMPLAINT CONTROL NUMBER: 26-AS-20250502135605

FACILITY NAME:	CAMPBELL VILLAGE		FACILITY NUMBER:	435294224
ADMINISTRATOR:	DE OCAMPO, GERALYN		FACILITY TYPE:	740
ADDRESS:	290 N. SAN TOMAS AQUINO ROAD		TELEPHONE:	(408) 378-2535
CITY:	CAMPBELL	STATE: CA	ZIP CODE:	95008
CAPACITY:	90	CENSUS:	DATE:	05/07/2025
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Administrator Geralyn De Ocampo		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

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Facility is not providing assistance due to staff shortage.

INVESTIGATION FINDINGS:

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On 5/2/2025 the Department received a complaint alleging that facility staff are not providing assistance due to staff shortage. It has been alleged that a resident sustained a fall at an unknown date and staff responded within 20-30 minutes.

On 5/7/2025 Licensing Program Analysts (LPAs) Marcella Tarin and Manuel Monter investigated the allegation that facility staff are not providing assistance due to staff shortage.

During the investigation, LPAs interviewed 6 staff S1-S6. Staff S1 and S2 stated staff do not respond to resident’s request for assistance in a timely manner. S1 and S2 stated caregivers are talking and ignoring resident’s pendant calls.

Staff S3 -S6 stated caregivers are providing resident’s requests for assistance in a timely manner.
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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jin Jackie	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marcella Tarin	TELEPHONE: (714) 328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2025

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 5

Control Number 26-AS-20250502135605

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: 05/07/2025

NARRATIVE

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LPAs interviewed Residents R1-R10. 9 Out of 10 residents (R2-R10) stated caregivers are providing assistance in a timely manner when resident’s request for assistance. R1 stated approximately 3 to 4 weeks ago he/she sustained a fall in the morning in his/her bathroom. R1 stated he/she was yelling for help for approximately 20 to 30 minutes until a caregiver arrived.

During the visit LPAs tested pendant in Room #222. The facility responded to this pendant test in 17 minutes and 30 seconds. (LPAs observed resident in #223 exit his/her room and requested for water. LPAs observed caregiver leave the area to get the resident the requested water, the caregiver then responded to resident in Room #222). LPAs also tested pendant in Room #226. A caregiver responded in 2 minutes to the pendant call in Room #226.

LPAs interviewed Care Coordinator (CC). CC stated the facility has an extra staff in the morning shift and the facility is not short staffed. CC stated he/she has no knowledge of R1 falling or R1 being hospitalization in the past two months.

LPAs reviewed progress notes for R1 for the months of April 2025 and May 2025. There were no documented falls for R1. LPAs also reviewed R1s hospital visits/fax communication file, and there is no mention or documentation of R1 falling in April 2025 and May 2025.

LPAs reviewed facility incident reports. There were not documented falls or hospitalization's for R1 in April 2025 and May 2025.

Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegation is UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegation did or did
not occur.

No deficiencies cited during today's visit per California Code of Regulations Title 22. An exit interview was conducted with Care Coordinator (CC) Gregg Madriaga and signed copy of this report was provided.

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SUPERVISOR'S NAME: Jin Jackie	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marcella Tarin	TELEPHONE: (714) 328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 5

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
05/02/2025 and conducted by Evaluator Marcella Tarin

COMPLAINT CONTROL NUMBER: 26-AS-20250502135605

FACILITY NAME:	CAMPBELL VILLAGE		FACILITY NUMBER:	435294224
ADMINISTRATOR:	DE OCAMPO, GERALYN		FACILITY TYPE:	740
ADDRESS:	290 N. SAN TOMAS AQUINO ROAD		TELEPHONE:	(408) 378-2535
CITY:	CAMPBELL	STATE: CA	ZIP CODE:	95008
CAPACITY:	90	CENSUS:	DATE:	05/07/2025
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Care Coordinator Gregg Madriaga		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

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Facillity did not provide transportation.
Facility staff are not qualified to provide care.

INVESTIGATION FINDINGS:

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On 5/2/2025 the Department received a complaint alleging that facility staff did not provide transportation.

On 5/7/2025 Licensing Program Analysts (LPAs) Marcella Tarin and Manuel Monter investigated the allegation that facility staff did not provide transportation.

During the investigation, LPAs interviewed 6 staff S1-S6. S1-S5 stated the facility has a transportation schedule which residents can sign up to be taken to his/her appointments. S1-S5 stated they are not aware of any residents missing his/her appointment. S6 stated he/she does not have any knowledge of how the facility transports residents to their appointments but is aware that the facility does have a van to transport residents.

Page 1 Out of 3

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Jin Jackie	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marcella Tarin	TELEPHONE: (714) 328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 26-AS-20250502135605

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: 05/07/2025

NARRATIVE

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LPAs interviewed Residents R1-R10. 8 out of 10 residents (R1-R5, R7, R9, and R10) stated the facility is providing transportation to residents for their appointments on Tuesdays and Thursdays. 2 Out of 10 residents (R6 and R8) stated they do not use facility transportation for his/her appointments. R1 stated the facility has been taking him/her to his/her appointments on Tuesdays and Thursday but stated he/she has missed appointments but does not know the dates of the appointments missed.

LPAs interviewed Care Coordinator (CC). CC stated the facility has a transportation schedule for resident appointments on Tuesdays and Thursdays. CC stated if a resident has an appointment that is on Tuesday or Thursday and the facility is unable to meet a resident's transportation request, example too many appointments, the facility will pay for and provide additional transportation via private transportation service. CC stated that residents are aware that the facility provides transportation on Tuesdays and Thursdays (the facility prefers an advance weeks notice for appointments). CC stated he/she is not aware of any incidents of residents missing his/her appointments.

LPAs reviewed transportation schedules for April 2025 and May 2025. After review, the facility is scheduling transportation for residents, including R1, on Tuesdays and Thursdays. Residents’ names, dates and appointment locations are noted on the transportation schedule.

The Department has completed the investigation of the above allegation. Based on interviews conducted and records review, the Department has found that the above allegation is UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

Facility staff are not qualified to provide care.

On 5/2/2025 the Department received a complaint alleging that facility staff are not qualified to provide care.

On 5/7/2025 Licensing Program Analysts (LPAs) Marcella Tarin and Manuel Monter investigated the allegation that facility staff are not qualified to provide care.

Page 2 Out of 3.

SUPERVISOR'S NAME: Jin Jackie	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marcella Tarin	TELEPHONE: (714) 328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 26-AS-20250502135605

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: 05/07/2025

NARRATIVE

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During the investigation, LPAs interviewed 6 staff S1-S6. All staff interviewed stated they have received training to provide care to residents. All staff interviewed stated all facility staff have been trained and are qualified to provide care.

LPAs interviewed Resident R1-R10. 9 Out of 10 residents (R2-R10) stated facility staff has been providing adequate assistance with Activities of Daily Living (ADLs) such bathing, changing, escorting, etc. R1 stated facility staff are not qualified because they are not medically trained to give injections.

LPAs interviewed Care Coordinator (CC). CC stated all staff receive training on how to care for residents. CC stated staff know how to perform their duties to include bathing, changing, escorting, etc.

LPAs reviewed staff training records for the year 2025, which included in-service training but not limited to infection control, transfers/gait belt use, Dementia care and behaviors.

The Department has completed the investigation of the above allegation. Based on interviews conducted and records review, the Department has found that the above allegation is UNFOUNDED, meaning that the allegation is false, could not have happened and/or are without a reasonable basis

No deficiencies cited during today's visit per California Code of Regulations Title 22. An exit interview was conducted with Care Coordinator (CC) Gregg Madriaga and signed copy of this report was provided.

Page 3 Out of 3.

SUPERVISOR'S NAME: Jin Jackie	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marcella Tarin	TELEPHONE: (714) 328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2025

LIC9099 (FAS) - (06/04)

Page: 5 of 5