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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445200538
Report Date: 06/30/2022
Date Signed: 06/30/2022 04:27:44 PM

Document Has Been Signed on 06/30/2022 04:27 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:CAMPHILL COMMUNITIES CALIFORNIAFACILITY NUMBER:
445200538
ADMINISTRATOR:JON FLINT & JENNIFER RYDERFACILITY TYPE:
735
ADDRESS:3920 FAIRWAY DRIVETELEPHONE:
(831) 476-5492
CITY:SOQUELSTATE: CAZIP CODE:
95073
CAPACITY: 6CENSUS: DATE:
06/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:01 PM
MET WITH:Jon FlintTIME COMPLETED:
04:27 PM
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 06/30/2022. Upon arriving, LPA spoke to Administrator Jon Flint (Admin) outside of the facility. Admin stated that the facility had discovered COVID positives for both residents and staff within the facility. COVID positives were discovered via antigen test on the evening of 06/29/2022. Facility is still within the 24 hour window to report COVID positives to licensing. LPA completed the initial COVID positive intake survey, and concluded the visit as an attempted annual. LPA will return to the facility for annual inspection after facility is clear of COVID.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Ryker Heberle
LICENSING EVALUATOR SIGNATURE: DATE: 06/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/30/2022
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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