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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445200538
Report Date: 07/23/2024
Date Signed: 07/23/2024 03:31:19 PM

Document Has Been Signed on 07/23/2024 03:31 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: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:
07/23/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Jennifer Ryder - AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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On 7/23/2024, at 1:00 p.m. Licensing Program Analyst (LPA) Maria (Mita) Partoza, conducted an unannounced case management for the incident report that was received on 6/4/2024. LPA met with administrator (ADM) Jennifer Ryder and stated the purpose of the visit.

The facility serves adults from 18 to 59 years old and identified as adult residential facility (ARF) and licensed to serve six (6) developmentally disabled clients. All must be ambulatory and license is subject to the terms and conditions of the hospice waiver for two (2) clients.

LPA conducted an interview with ADM and discussed the self reported elopement of one of their resident (R1) that occurred in 6/2/2024. ADM stated that R1s behavior is nothing new and has been on going since he was admitted to the facility in 2010. R1s behavior is reported to CCLD when behavior of elopement occurs. ADM presented the fax sent to CCLD from 2/6/2021 to present and provided a copy of the report.

Based on interview and record review R1 has autism and obsessive compulsive traits and exhibits lack of impulse controls for things that R1 likes such but not limited to food. R1s impulse disorder causes R1 to seek food that can be easily accessed. ADM stated that R1 can request food at anytime, but R1s food intake needs to be supervised or monitored as ordered by the R1s primary care physician (PCP). ADM stated that R1 is an early riser (6:00 a.m.) and likes to run accompanied by staff.


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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE: DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/23/2024
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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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: CAMPHILL COMMUNITIES CALIFORNIA
FACILITY NUMBER: 445200538
VISIT DATE: 07/23/2024
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At 1:40 p.m. LPA with ADM walked and toured the path that R1 takes to go over to the other facility to access food. LPA observed that the path or side walk and not paved and the distance to the road is about 4 feet. The traffic is minimal with safety road bumps. There are no light posts along the road. The distance between the two facility is about 700 feet. Based on documentation review, R1s PCP stated that R1 is able to walk to the neighboring facility without any assistance. R1s needs and services plan after the incident was updated.

LPA observed that one of the refrigerator that is located on the exterior side of the kitchen has a lock that contains food. ADM stated the refrigerator stores cheese and butter and other food items that R1 likes to consume in excess. ADM stated that the rest of the residents have access to the refrigerator and each resident has a key, except for R1. Based on documentation, R1s PCP recommends that food that R1 likes to consume in large quantities, such as butter and cheese should not have open access to R1. Open access to food by R1 endanger R1s health when consumed in large amount.

ADM stated, to prevent elopement, a plan was created to help R1 not to seek food from the neighboring facility by introducing R1 to the NOC (nocturnal) staff and help R1 access food with supervision at anytime. ADM stated that R1 was able to follow through with the new procedure and asked the NOC staff help find food within the facility where R1 resides. To help R1 with impulse control, the facility is looking into YAI California Start program to help R1 with impulse control.

LPA requested documents from ADM, such as but not limited to LIC 500, LIC 602, LIC 625, special incident reports, and physician's order.

No deficiencies were cited during today's case management per California Code of Regulations (CCR) Title 22. An exit interview was conducted with administrator Jennifer Ryder and a copy of the report was provided.

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end of report

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
LIC809 (FAS) - (06/04)
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