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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445200757
Report Date: 03/29/2022
Date Signed: 03/29/2022 04:23:27 PM

Document Has Been Signed on 03/29/2022 04:23 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 CALIFORNIA IIFACILITY NUMBER:
445200757
ADMINISTRATOR:JON FLINT & JENNIFER RYDERFACILITY TYPE:
735
ADDRESS:4096 FAIRWAY DRIVETELEPHONE:
(831) 476-5492
CITY:SOQUELSTATE: CAZIP CODE:
95073
CAPACITY: 6CENSUS: 4DATE:
03/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Jon FlintTIME COMPLETED:
04:28 PM
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 03/29/2022 at 03:00pm. LPA met with facility Administrator Jon Flint (Admin).

LPA toured the facility, including 3 living rooms, kitchen, dining room, laundry room, office 11 bedrooms, 4 bathrooms, and back yard. Admin confirmed that all staff and residents have been vaccinated and boosted.

Facility Mitigation plan has already been submitted and approved. No prohibited items noted in resident rooms. All emergency exits noted to be clear of obstruction. All rooms in facility noted to be clean and well maintained. Hand sanitizers, soap, and paper supplies were observed to be available. At least 2 days' supply of perishable food and at least 1 week's supply of non-perishable food was observed on the premises.

Fire extinguisher observed to be inspected in March 2022. All cleaning supplies and chemicals noted to be in locked cabinets and closets. Smoke/carbon monoxide detectors were observed.

Facility observed to have designated entry point. Staff took LPA's temperature and screened for symptoms. 30 day supply of PPE was observed. Hand washing signs were observed in facility bathrooms. Water temperature observed to be 110 *F in 2 bathrooms. Social distancing signs observed to be posted in all public areas.

No deficiencies cited during today's visit. This report was reviewed with Administrator Jon Flint and a copy of the signed report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Ryker Heberle
LICENSING EVALUATOR SIGNATURE: DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/29/2022
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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