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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445200757
Report Date: 05/13/2026
Date Signed: 05/13/2026 01:58:51 PM

Document Has Been Signed on 05/13/2026 01:58 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:		JOHANNES SCHLITZFACILITY TYPE:
735
ADDRESS:4096 FAIRWAY DRIVETELEPHONE:
(831) 476-5492
CITY:SOQUELSTATE: CAZIP CODE:
95073
CAPACITY: 4CENSUS: 4DATE:
05/13/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Designated Administrator (ADM) Johannes Schlitz
Administrator (ADM) Daniel Lustre		TIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced Case management incident visit to follow up on an incident that occurred on 5/10/2026. LPA met with Designated Administrator (ADM) Johannes Schlitz and Administrator (ADM) Daniel Lustre LPA stated the purpose of the visit.

On 5/12/2026 the Department received a Special Incident Report (SIR) for an incident that occurred on 5/10/2026. Per the SIR, on 5/10/2026 Designate ADM was informed by Staff, that a client, referred to as C1, "had ingested approximately 5-10 tablets of Advil 200 mg while in a community vehicle following a beach outing." C1's responsible parties were notified, including poison control. C1 was monitored for side effects. Per the report, C1 returned to baseline and had minor side effect of an upset stomach.

On 5/12/2026 LPA Tarin called and spoke with Designated ADM regarding the incident. During the call, LPA requested pertinent documentation to be submitted to the Department by 5/13/2026.

During today's visit, LPA interviewed 3 Staff, and 1 Client. Designated ADM provided LPA with the documentation requested on 5/12/2026. During interviews, Staff S3 stated after a facility beach outing on 5/10/2026, C1 appeared 'stressed' upon returning back to the facility. S3 stated C1 entered the facility, then walked back out to the facility vehicle. S3 stated he/she followed C1 to the vehicle. S3 stated C1 did not want to exit the vehicle. S3 then walked to get another staff, and upon returning to the vehicle, S3 saw C1 place something in his/her mouth. S3 stated he/she had inadvertently left a bottle of Advil in the facility vehicle lock box (glove compartment) on 5/10/2026. S3 states facility management was informed of the incident.
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NAME OF LICENSING PROGRAM MANAGER: Christine Kabariti
NAME OF LICENSING PROGRAM ANALYST: Marcella Tarin
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/13/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 05/13/2026
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On 5/13/2026, LPA Tarin interviewed C1. C1 did not provide additional information regarding this incident.

Review of C1's Needs and Services Plan dated 5/1/2026, C1 has developmental impairment, with behaviors of grabbing and consuming food or drink items when C1 becomes agitated.

Review of C1's Physician's Report dated 3/24/2025, C1 cannot administer and store own medications.

LPA Tarin inspected the facility vehicle with Designated ADM and ADM. LPA did not observe any medications or hazardous items in the vehicle.

LPA Tarin reviewed S3's file and observed S3 to have medications training on 6/11/2025 and 6/12/2025.

A deficiency is being cited per California Code of Regulations, Title 22. See LIC809D for more information. An exit interview was conducted with ADM Daniel Lustre and Designated ADM Johannes Schlitz, and a copy of this report and appeal rights were provided.

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END OF REPORT
NAME OF LICENSING PROGRAM MANAGER: Christine Kabariti
NAME OF LICENSING PROGRAM ANALYST: Marcella Tarin
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/13/2026 01:58 PM - It Cannot Be Edited


Created By: Marcella Tarin On 05/13/2026 at 01:22 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: CAMPHILL COMMUNITIES CALIFORNIA II
FACILITY NUMBER: 445200757

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/14/2026
Section Cited
CCR
80065(a)

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80065 Personnel Requirements (a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs. This requirement was not met as evidenced by:
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ADM will submit a Plan of Correction on how the facility will ensure staff are providing the services necessary to meet individual client needs, as well as ensuring medications are centrally stored (locked and inaccessible to clients in care). ADM to submit POC to CCLD by POC due date of 5/14/2026.
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Based on interviews and records reviewed on 5/10/2026, Client C1 ingested 5-10 Advil pills when Staff S3 left a bottle of Advil tablets, unlocked in the lock box (glove compartment) of a facility vehicle. This poses an immediate Health, Safety, or Personal Rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Christine Kabariti
NAME OF LICENSING PROGRAM MANAGER:
Marcella Tarin
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2026


LIC809 (FAS) - (06/04)
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