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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445200538
Report Date: 06/27/2024
Date Signed: 06/28/2024 08:01:40 AM

Document Has Been Signed on 06/28/2024 08:01 AM - 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/
DIRECTOR:
JENNIFER RYDERFACILITY TYPE:
735
ADDRESS:3920 FAIRWAY DRIVETELEPHONE:
(831) 476-5492
CITY:SOQUELSTATE: CAZIP CODE:
95073
CAPACITY: 6CENSUS: 5DATE:
06/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Jennifer RyderTIME VISIT/
INSPECTION COMPLETED:
12:32 PM
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Licensing Program Analyst (LPA) Steve Chang conducted a unannounced annual inspection visit and met with Administrator (ADM) Jennifer Ryder and assistant administrator Johannes Schlitz.

LPAs checked 3 resident record files and 3 staff record files.

LPA observed 2 staff in the facility. All the 5 residents are on vacation and will be back this afternoon.

LPA toured the facility inside out with ADM. LPA toured living room, family room, kitchen, dinning area, and laundry room. Medication room, knives closet, and cleaning product room were observed locked.

There are 5 resident bedrooms, 6 staff rooms and 7 restrooms in the facility. Room temperature was observed at 69 degree F, and hot water temperature was observed at 118 degree F. The temperature of refrigerator was observed at 38 degree F, and the temperature of the freezer was observed at -2 degree F. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. First aid box, flash lights, and night light were observed in the facility. The last time the facility conducted the emergency drill is 5/14/2024.

The facility is equipped with smoke and carbon monoxide detectors. The facility equipped with fire alarm system. ADM tested the smoke and carbon monoxide detectors, and they were working fine. The fire extinguishers were observed on service on 03/11/2024. There is a pool at the backyard and was observed locked. LPA inspected the backyard, there was no obstruction to block the walkway.

No citation noted today. Exit interview was conducted with ADM. The reports were provided to ADM for signature. A copy of this report was provided to ADM.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2024
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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