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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294224
Report Date: 10/10/2024
Date Signed: 10/10/2024 05:02:43 PM


Document Has Been Signed on 10/10/2024 05:02 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: 66DATE:
10/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator Geralyn De OcampoTIME COMPLETED:
05:10 PM
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Licensing Program Analysts (LPAs) Marcella Tarin and Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator (ADM) Geralyn De Ocampo . LPAs toured the interior and exterior of the facility with ADM to include the dining room, kitchen, resident bedrooms, hallway bathrooms, and patio areas.

LPAs toured the kitchen area and observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. The refrigerator maintained at 37.8 degrees F and the freezer maintained at below 0 degrees F. The facility temperature is maintained at 72 degrees F.

LPAs toured the facility inside and out, including 9 resident bedrooms. 9 out of 9 resident bedrooms inspected had functioning lights, a bed, cleaning bedding, a chair, a dresser and storage for resident personal belongings. While touring resident bedroom #111, LPAs attempted to open sliding glass door and observed a plastic tube obstructing the sliding door, preventing the door from opening (photos taken). ADM removed plastic tube obstructing sliding door during visit. LPA asked ADM why the plastic tube was obstructing the sliding door. ADM stated the tube was placed to prevent caregivers from going in and out through the door. LPA advised ADM that all resident passageways must be free of obstruction.

While touring Memory Care, LPAs tested delayed egress door #4 (next to resident rooms #124 and #125). LPAs pushed the door completely open, and the delayed egress did not sound the alarm. LPAs informed ADM that the door did not sound. A caregiver activated egress door with a key, and the delayed egress was activated. LPAs tested the door again and it activated the alarm. LPAs asked ADM why the delayed egress alarm was not activated. ADM stated she did not know why it was not activated, and that it's policy for the alarm to be on at all times.

SEE LIC809-C
SUPERVISOR'S NAME: Jin JackieTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marcella TarinTELEPHONE: (714) 328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2024
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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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
VISIT DATE: 10/10/2024
NARRATIVE
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LPAs measured the water temperature between 116 to 118 degrees F in two restrooms on the first floor of the facility. The facility was equipped with smoke and carbon monoxide detectors. Fire extinguishers were last serviced on 02/01/2024. LPAs observed the facility first aid kit and it was observed to be complete. The facility fire/earthquake drill log was reviewed. The facility's last emergency drill was on 09/21/2024.

LPAs reviewed facility records for 4 staff and 4 residents. LPAs observed 4 out of 4 staff records as complete to include fingerprint clearance, health screening. LPAs observed 4 out of 4 resident records as complete to include a medical assessment, TB result, updated appraisal/needs and services plan, identification and emergency contact information, personal rights, and consent forms.


LPAs reviewed 4 residents Centrally Stored Medication and Destruction Records (CSMDR). LPAs observed 4 out of 4 CSMDRs are complete with all medications accounted and documented. LPAs observed the medication storage area was locked and inaccessible to residents in care.

LPAs interviewed 4 residents and 1 staff member.

Deficiencies were cited during today's visit as per California Code of Regulations Title 22. See LIC809-D for more information. This report was reviewed with ADM Geralyn De Ocampo and a copy of the signed report and appeal rights were provided

SUPERVISOR'S NAME: Jin JackieTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marcella TarinTELEPHONE: (714) 328-5152
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/10/2024 05:02 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: 10/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above. While touring Memory Care, LPAs tested delayed egress door #4 (next to resident rooms #124 and #125). LPAs pushed the door completely open, and the delayed egress did not sound the alarm which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/11/2024
Plan of Correction
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Staff member activated the delayed egress with a key and the door alarm was activated during visit. ADM stated she will conduct an in-service training with staff regarding delayed egress policy and submit documentation of in-service training by POC due date. ADM will also submit a letter of understanding of the regulation cited and submit to LPA by POC due date.
Type A
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

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. While touring resident bedroom 111, LPAs observed a plastic tube obstructing the sliding glass door, preventing the door from opening which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/11/2024
Plan of Correction
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ADM removed plastic tube from the sliding glass door during visit. ADM will submit a letter of understanding of the regulation cited and submit to LPA by POC due date.
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: Jin JackieTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marcella TarinTELEPHONE: (714) 328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3