435294224-3-3-2022-26-AS-KHOS-CEH2TT-20220516174116

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435294224
Report Date: 03/03/2022
Date Signed: 03/03/2022 02:47:52 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
09/28/2021 and conducted by Evaluator Ryker Heberle

COMPLAINT CONTROL NUMBER: 26-AS-20210928083209

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: 62	DATE:	03/03/2022
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Geralyn de Ocampo		TIME COMPLETED:	10:58 AM

ALLEGATION(S):

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Resident was sexually assaulted while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ryker Heberle conducted an unannounced visit to deliver the complaint investigation finding. LPA met with Administrator Geralyn de Ocampo.

Department opened the complaint regarding the above allegation on 09/28/2021. Between the dates of 09/28/2021 and 12/07/2021 9 individuals were interviewed including: 1 family member of resident, 4 facility residents, 2 facility staff, 1 contract agency staff, 1 law enforcement officer.

Throughout the course of the investigation, the department reviewed resident physician's report, resident needs and services plan, staff schedule, and agency agreement between the facility and contractors.

Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022

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-20210928083209

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: CAMPBELL VILLAGE	FACILITY NUMBER: 435294224
	VISIT DATE: 03/03/2022

NARRATIVE

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During interviews with 4 residents, 1 out of 4 residents stated that contracted facility staff had touched them inappropriately. 3 out of 4 residents had stated that they had never felt unsafe with staff nor been approached inappropriately while receiving care from staff. 4 out of 4 residents stated that they are satisfied with the quality of care provided by the facility.

In interviews with facility staff 2 out of 2 facility staff members stated that they had never had any residents report or express concern over potential sexual assault at the facility. 2 out of 2 facility staff had never been given cause to suspect potential sexual abuse from other staff members, contracted or otherwise. In interviews with the facility's additional staffing contracting agency, Care On Call, one administrative staff stated that they have never had reports from Campbell Village regarding potential sexual assault. 3 out of 3 parties interviewed stated that the suspected abuser (SA) identified by 1 out of 4 residents had no prior history of abuse or misconduct on record. SA was discharged from Campbell Village and no longer works for Care On Call for reasons outside of alleged incident.

During course of investigation, The department made 4 attempts to interview SA. After agreeing to meet with the department, SA failed to arrive at the designated meeting location, and was unable to be contacted afterward. As of 01/01/2022, SA has been unable to be contacted by both police and department investigators.

The Department has investigated the above allegation. Based on interviews conducted and records reviewed, 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.

This report was reviewed with Administrator Geralyn de Ocampo and a copy of the report was provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022

LIC9099 (FAS) - (06/04)

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