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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294224
Report Date: 10/23/2024
Date Signed: 10/23/2024 02:49:31 PM


Document Has Been Signed on 10/23/2024 02:49 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:DE OCAMPO, GERALYNFACILITY TYPE:
740
ADDRESS:290 N. SAN TOMAS AQUINO ROADTELEPHONE:
(408) 378-2535
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY:90CENSUS: DATE:
10/23/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Geralyn De OcampoTIME COMPLETED:
03:00 PM
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On 10/23/2024 San Bruno Regional Office - San Jose Unit conducted a non-compliance conference office meeting with Administrator Geralyn De Ocampo, Representative of Licensee Board Marife Duewel, Resident Care Coordinator Greg Madriaga, and Memory Care Manager Audie Tonod.

Regional Manage Vivien Helbling, Licensing Program Manager Jackie Jin, and Licensing Program Analysts David Marrufo and Marcella Tarin were present in the meeting.

During the non-compliance meeting, the following serious violations were discussed: 87303(a) Maintenance and Operation, 87307(d)(6) Personal Accommodations and Services, 87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities, and 87303(i)(1)(A) Maintenance and Operation.

During this meeting, the compliance plan was developed and discussed with the licensee which includes more frequent monitoring inspection visits to ensure compliance with this compliance plan and Title 22 Regulations for 2 years. Licensee was provided the link below for resources and guidance to improve facility operations:

https://www.cdss.ca.gov/inforesources/community-care/resource-guide-for-providers.

An LIC421IM form issuing an immediate civil penalty of $500 was given to Marife Duewel, Representative of Licensee Board. The immediate civil penalty of $500 was issued today due to absence of supervision that occurred on 08/12/2024 in which a Memory Care resident eloped from the facility without staff supervision.

This report was reviewed with Representative of Licensee Board Marife Duewel and Administrator Geralyn De Ocampo and a copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2024
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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