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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294224
Report Date: 10/17/2022
Date Signed: 10/17/2022 11:48:46 AM


Document Has Been Signed on 10/17/2022 11:48 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:STAMM, ANELLIFACILITY TYPE:
740
ADDRESS:290 N. SAN TOMAS AQUINO ROADTELEPHONE:
(408) 378-2535
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY:90CENSUS: DATE:
10/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:02 AM
MET WITH:Geralyn de OcampoTIME COMPLETED:
11:51 AM
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 10/17/2022. LPA met with facility Administrator Geralyn de Ocampo (Admin).

LPA toured the facility, including living room, kitchen, dining room, laundry room, 10 bedrooms, 2 public bathrooms, back patio, front yard, salon, activities room, dining room, and kitchen. All staff members observed to be wearing masks. Admin confirmed that all staff and residents have been vaccinated.

Facility infectious control plan has already been submitted. No prohibited items noted in resident rooms. All rooms in facility noted to be clean and well maintained. Hand sanitizers, soap, and paper supplies were observed to be available. At least 2 days' supply of perishable food and at least 1 week's supply of non-perishable food was observed on the premises. Fire extinguishers observed to be inspected in January of 2022.

Facility observed to have designated entry point. Staff took LPA's temperature and screened for symptoms. 30 day supply of PPE observed. All restrooms stocked with paper towels. Water temperature observed to be between 98.7 and 96.4*F. Hand washing signs observed in all bathrooms. All bathrooms had garbage cans with foot operated lid. Social distancing signs observed to be posted in all public areas. The facility is currently accepting visitors inside the facility, including residents' bedrooms.

Deficiency cited during today's visit. This report was reviewed with Administrator Geralyn de Ocampo and a copy of the signed report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2022
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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Document Has Been Signed on 10/17/2022 11:48 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(1)
80088(e)(1) Furniture, Fixtures, Equipment, and Supplies - (e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as the water temperature was measured to beneath 105 *F in 3 out of 3 tested bathrooms which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/24/2022
Plan of Correction
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Facility is currently in the process of brining in maintanance worker to inspect water heater. Facility to submit daily temperature log and schedule a plumber to fix the water heater by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2022
LIC809 (FAS) - (06/04)
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