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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445200757
Report Date: 03/12/2025
Date Signed: 03/12/2025 04:10:07 PM

Document Has Been Signed on 03/12/2025 04:10 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 CALIFORNIA IIFACILITY NUMBER:
445200757
ADMINISTRATOR/
DIRECTOR:		JENNIFER RYDERFACILITY TYPE:
735
ADDRESS:4096 FAIRWAY DRIVETELEPHONE:
(831) 476-5492
CITY:SOQUELSTATE: CAZIP CODE:
95073
CAPACITY: 6CENSUS: 4DATE:
03/12/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Jennifer Ryder, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced annual inspection and met with Administrator (ADM) Jennifer Ryder. There were 4 clients and 4 staff present during the annual inspection.

LPA toured the interior and exterior of the facility with ADM to include but not limited to the kitchen, office, client rooms, dining room, bathrooms, back and front of the facility. Facility thermostat temperature display was observed at 68 degrees F. All exit and passageways were free and clear of obstruction.

LPA toured the kitchen area and observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA measured refrigerator temperature at 37 degrees F and Freezer at 0 degrees F.

LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to clients in care.

The facility was equipped with smoke and carbon monoxide detectors. All smoke detectors functioned properly when tested by ADM. Fire extinguishers were last serviced on 3/10/2025. LPA reviewed the facility first aid kit. The facility emergency drill log was reviewed. The facility's last drill was conducted on 2/13/2025. Drills are being conducted monthly.

LPA toured 4 client rooms. 4 out of 4 client rooms have a bed, functioning lights, dresser/table, a chair, bedding and space for personal belongings. LPA toured 6 client bathrooms. 6 out of 6 bathrooms had hand soap, paper towels, functioning lights, and covered trash bins. LPA measured water temperature at 115.8 degrees F.

Page 1 of 2. See LIC809C

SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE: DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2025
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: 03/12/2025
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LPA reviewed 4 client records. 4 out of 4 clients records included emergency contact information, physician’s report, needs and service plans, and personal rights.

LPA reviewed 4 resident’s Centrally Stored Medication and Destruction Records (CSMDR’s).

LPA reviewed client’s P&I with the ADM. 4 out of 4 client’s P&I records were documented accurately.

LPA reviewed 4 staff records. 4 out of 4 staff records included fingerprint background clearance, medical assessment with TB result, personnel record, and staff training.

ADM provided LPA with a current copy of the facility's LIC500 dated 3/01/2025, an updated sketch of the facility dated 3/12/2025 during today's inspection.

No deficiencies were cited during today's visit per California Code of Regulations Title 22. An exit interview was conducted with Administrator Jennifer Ryder and a signed copy of this report was provided.

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SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
LIC809 (FAS) - (06/04)
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