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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294224
Report Date: 08/14/2024
Date Signed: 08/14/2024 04:03:18 PM


Document Has Been Signed on 08/14/2024 04:03 PM - 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:
08/14/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:TIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) David Marrufo and Santino Fortes conducted an unannounced Case Management visit and met with Audie Ton-Od, Memory Care Supervisor. The purpose of the visit was to respond to an incident report that the facility submitted to the Department on 8/12/24. The incident report stated that on 8/12/24 memory care resident R1 left the facility unassisted. A neighbor found the resident and called the facility at 2:35PM. At 2:50pm, facility staff found the resident in the neighboring community and paramedics took the resident to the hospital. R1 was observed to have scrapes to the left arm and left forehead with minimal bleeding.

R1's Physician Report states that R1 has dementia and is not allowed to leave the facility unassisted.

During visit, LPAs interviewed staff S1 and S2. S1 stated that it is still unknown how R1 left the facility unassisted. S2 stated to have observed R1 in the facility hallway around 2:15 PM, but did not observe R1 leave the facility.

During visit, LPAs tested 4 out of 4 Memory Care exit doors and all 4 doors had functioning alarms.

A deficiency was cited as per California Code of Regulations Title 22. See LIC809-D page for more information. This report was reviewed with Audie Ton-Od, Memory Care Supervisor, and a copy of this report and the appeal rights were provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2024
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 08/14/2024 04:03 PM - 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: 08/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/15/2024
Section Cited
CCR
87468.2(a)(4)

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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:
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Licensee agrees to submit a Plan of Correction to CCL by POC date stating how the facility staff will receive in-service training on preventing Memory Care residents from leaving the facility unassisted. Once training is complete, the Licensee agrees to submit training records including names of staff
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(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Licensee did not ensure that resident R1 did not elope from the facility unassisted, which poses an immediate safety risk to residents in care.
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trained, training dates, training topics, and name(s) and qualifications of trainer(s) to CCL.

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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: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2024
LIC809 (FAS) - (06/04)
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