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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445200757
Report Date: 03/25/2024
Date Signed: 03/28/2024 10:09:15 AM

Document Has Been Signed on 03/28/2024 10:09 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
CENTRAL COAST CR/RES, 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:
03/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Jon Flint & Jennifer RyderTIME COMPLETED:
05:00 PM
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On 3/25/2024 Licensing Program Analyst (LPA) Maria (Mita) Partoza arrived at the facility at approximately 2:05 p.m. and conducted an unannounced Required 1 Year inspection LPA met with Associate Director (AD) Jon Flint and Administrator (ADM) Jennifer Ryder residents were resting at the time of the visit.

The current census of the facility is 4 resident and 7 staff.

LPA toured the facility with AD, inside and outside, but not limited to the following area, kitchen, dining, activity room, resident rooms and bathroom.

LPA observed that the residents bedrooms has furniture for storing personal belongings, bed, clean linens and working lights. Bathrooms in the home and were observed to be free from debris, has sufficient supply of toiletries, paper towels and other personal hygiene products used by residents in care. Shower areas have grab bars and non- skid surfaces. Hot water temperature was tested in 2 random bathrooms and measured. Temperature ranges from 111.4 degree F to 120 degree F respectively.

LPA observed that the kitchen and dining area, laundry, living and activity rooms to be in good order and free from any debris. LPA observed toxic material, cleaning supplies, laundry supplies and sharps are in a locked cabinet.

LPA observed facility has has sufficient 2 days perishable and 7 days non-perishable food supplies. Fire extinguisher were last inspected 3/11/2024, smoke alarms, carbon monoxide detectors and emergency first aid kit were observed throughout the home.

LPA toured the observed that hallways and walkways are free from obstructions.

page 1 continued on page 2 LIC 809C

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE: DATE: 03/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/25/2024
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 II
FACILITY NUMBER: 445200757
VISIT DATE: 03/25/2024
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Staff records were reviewed with current first aid, health screening and training. Residents' records and medication logs were reviewed. Medications are labeled and given as prescribed. The medications are stored and locked in the medication room. P & I money was audited with the ADMs

Per the facility's log book, fire drills are conducted monthly and earth quake drills are conducted quarterly.

No deficiencies cited during today's inspection. Exit interview conducted with Associate Director Jon Flint and Administrator Jennifer Ryder, a copy of the signed report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2024
LIC809 (FAS) - (06/04)
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