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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
435294224
Report Date:
10/18/2024
Date Signed:
10/18/2024 03:17:00 PM
Document Has Been Signed on
10/18/2024 03:17 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 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:
66
DATE:
10/18/2024
TYPE OF VISIT:
POC
UNANNOUNCED
TIME BEGAN:
02:30 PM
MET WITH:
Administrator Geralyn De Ocampo
TIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Marcella Tarin and Licensing Program Manager (LPM) Jackie Jin conducted a case management to follow up on deficiencies that were cited on 10/10/2024. LPA and LPM met with Administrator (ADM) Geralyn De Ocampo.
LPA and LPM observed all egress doors to be alarmed and functioning when tested. LPA and LPM toured 4 resident bedrooms. 3 out of 4 resident bedroom sliding glass doors were observed to be free of obstruction. 1 out of 4 resident bedroom sliding glass doors was observed to have a locking mechanism preventing the sliding glass door from opening. Maintenance staff unlocked the locking mechanism and the sliding glass door was opened. LPA And LPM advised ADM to create a log to check on resident's sliding glass doors and ensure they are not locked and free from obstruction.
LPA Tarin cleared the deficiencies cited on 10/10/2024 during today's visit. A Letter of Deficiency Citations Cleared was printed and provided to ADM during today's visit.
No deficiencies were cited during todays visit. A copy of this report was provided to ADM Geralyn De Ocampo.
SUPERVISOR'S NAME:
Jin Jackie
TELEPHONE:
(714) 319-3786
LICENSING EVALUATOR NAME:
Marcella Tarin
TELEPHONE:
(714) 328-5152
LICENSING EVALUATOR SIGNATURE:
DATE:
10/18/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/18/2024
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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