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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294224
Report Date: 06/06/2024
Date Signed: 06/06/2024 02:42:56 PM


Document Has Been Signed on 06/06/2024 02:42 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:
06/06/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator Anelli StammTIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter arrived unannounced visit to open a complaint investigation. During the complaint investigation, a case management deficiencies visit was conducted due to violations discovered during the investigation process. LPA met with Administrator Anelli Stamm.

While investigating the complaint 26-AS-20240529150017, LPA reviewed facility incident reports for resident R1 from January 2024-June 6, 2024. Based on a review, the facility did not send any incident report for Resident R1, from January 2024- June 6, 2024.

While reviewing resident R1's facility file, documentation notes that R1 was seen at the hospital on 1/9/2024, 1/13/2024, 5/24/2024. ADM stated she does not know if the incident reports were sent as she does not have a fax confirmation for R1's hospital visits. LPA interviewed staff S1 who stated he/she did fax those incident reports, but does not have fax confirmation numbers.

Further review of the facility's internal incident report records, R1 had fallen on the following dates; February 7, 2024, March 2 and 7, 2024, and May 13, 2024. LPA interviewed staff S1. S1 stated he/she did not send incident reports for these falls because R1 did not go to the hospital. S1 stated he/she would send incident reports regrading falls in the future.

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Administrator Anelli Stamm and a copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2024
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 06/06/2024 02:42 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: 06/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/13/2024
Section Cited
CCR
87211(a)(1)(D)

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87211 Reporting Requirements (a)(1)(D) Any incident which threatens the welfare, safety or health of any resident... or other residents, or unexplained absence of any resident.
This requirement was not met as evidenced by;
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ADM stated she will send a letter of understanding regarding the Regulation. ADM stated she will send the letter by POC date, June 13, 2024.
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Based on interview & record review, the facility did not send an incident report regarding R1's falls on February 7, 2024, March 2 and 7, 2024, and May 13, 2024. Staff S1 stated he/she didn't send an incident report for these falls. This poses a potential health, safety or personal rights risk to persons in care.
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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: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2024
LIC809 (FAS) - (06/04)
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