435294224-7-10-2025-26-AS-MPAA-DJQVYY-20250719165153

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435294224
Report Date: 07/10/2025
Date Signed: 07/10/2025 11:32:19 AM

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
02/12/2025 and conducted by Evaluator Marcella Tarin

COMPLAINT CONTROL NUMBER: 26-AS-20250212162218

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: 61	DATE:	07/10/2025
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Administrator Geralyn De Ocampo		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Resident sustained stage 4 pressure injury while in care.
Staff mismanaged resident’s medication(s).

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced complaint investigation visit to deliver the findings on the complaint received by the Department on 02/12/2025 with the above allegations. LPA met with Administrator (ADM) Geralyn De Ocampo and stated the purpose of the visit.

On 2/13/2025 the Department conducted the initial 10-day complaint visit and requested copies of documents for review such as but not limited to physician’s report (LIC 602, appraisal needs and services plan, emergency contact information and medication records).

Based on investigation, R1 has a history of stage 2 pressure injury since 09/19/2023 and pain when moving. R1 received home health service care up to 11/16/2023 prior to moving to the facility. On 01/27/2024 R1 moved into the facility without any pressure injury.

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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: 07/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025

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

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20250212162218

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: 07/10/2025

NARRATIVE

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On 02/14/2024 home health services were initiated and record states that R1 developed a stage three pressure injury. On 04/04/2024 R1 was discharged from receiving home health services because the pressure injury has healed. On 10/15/2024, R1s home health services were renewed and was diagnosed with stage three pressure injury on the right heel, and stage one pressure injury on the sacral region. On 12/11/2024, R1 was discharged from home health services due to progressing pressure injury and was placed under hospice care.

Based on interview of R1, R1 stated he/she does not care to be turned due to pain when moving. R1 refuses the booties given by staff to protect his/her heels and does not allow staff to put the booties on.

Based on document review, facility staff informs R1s physicians when R1 refuses to be repositioned to prevent pressure injury. R1 is receiving palliative care daily for R1s wound and repositioning.

Based on interviews with 5 staff (S1 to S5). 5 Out of 5 staff revealed consistent statements that R1 refused to be repositioned and refused any care to help heal the pressure injury. S3 stated he/she explained to R1 that R1 needs to be repositioned based on R1s care plan.

Based on interviews with 5 witnesses (W1 to W5). W1 stated R1s health condition contributed to R1s pressure injury to worsen and R1 has a long history of refusing care. W1 stated, R1 is visited and cared for 5 times a week. W2 did not provide additional information. W3 stated that R1 refused to be re-hospitalized and wanted to stay in bed and R1 was non-compliant with ADL which led to progression of R1s wounds.

Based on interviews, document reviews and investigations, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation of neglect and lack of supervision causing R1 to develop pressure injury is UNSUBSTANTIATED, based on California Code of Regulation (CCR) Title 22.

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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: 07/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20250212162218

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: 07/10/2025

NARRATIVE

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Staff Mismanaging Medication

On 7/10/2025, LPA Tarin reviewed R1's Medication Administration Record (MAR) for January through April 2025. LPA did not observe discrepancies for medications administered to R1 for the months of January through April 2025.

LPA interviewed 2 staff (S6 and S7). 2 out of 2 staff stated R1 did not have any medications missing or misplaced during the months of January to April 2025.

Based on document review, LPA observed all medications orders documented, with no reports of missing or misplaced medication

Based on interviews with 5 witnesses (W1 to W5). W1 stated the facility 'misplaced' R1's medication in February 2025. W2 to W5 did not provide additional information.

Based on interviews, document reviews and investigations, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation of staff mismanaging R1's medication, and is UNSUBSTANTIATED, based on California Code of Regulation (CCR) Title 22.

No deficiencies are being cited during today's visit. An exit interview was conducted with ADM and a copy of this report was provided.

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End of Report

SUPERVISOR'S NAME: Jin Jackie	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marcella Tarin	TELEPHONE: (714) 328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025

LIC9099 (FAS) - (06/04)

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