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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202423
Report Date: 11/22/2021
Date Signed: 11/22/2021 05:27:01 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/24/2020 and conducted by Evaluator Steve Nguyen
COMPLAINT CONTROL NUMBER: 26-AS-20200324094020
FACILITY NAME:LAUREL HAVENFACILITY NUMBER:
435202423
ADMINISTRATOR:TERESITA SAMONTEFACILITY TYPE:
740
ADDRESS:1157 SOUTH SIXTH ST.TELEPHONE:
(408) 287-5074
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY:15CENSUS: 13DATE:
11/22/2021
UNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Merle LaurelTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff failed to provide adequate supervision to client while in care
Staff left client in soiled condition for an extended period of time
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Steve Nguyen arrived unannounced to deliver the complaint investigation finding. LPA met with Administrator, Merle Laurel, and explained the purpose of the visit.

On 3/24/2020 the Department received a complaint regarding the above allegations.

On 4/02/2020 LPA, David Marrufo, opened an unannounced 10-day Complaint investigation via Tele-Visit and advised the Administrator that the Department would be conducting the investigation.

Between 4/02/2020 and 11/8/2021, the Department reviewed: records, interviewed 2 staff, 1 witness, and Administrator. Records reviewed includes but are not limited to: staff rosters, Physician’s Reports, Need and Service Appraisal Report and Discharge documents from Santa Clara Valley Medical Center.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Steve Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 26-AS-20200324094020
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: LAUREL HAVEN
FACILITY NUMBER: 435202423
VISIT DATE: 11/22/2021
NARRATIVE
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2 staff and Administrator: Denies all allegations. 1 Witness affirmed all allegations.

Records reviewed indicated that there’s no gap in service. Physician Report stated that resident is independent in toilet needs. Needs and Services Appraisal Report affirmed the findings in Physician’s Report. Discharge papers does not indicate any altered mental status upon release.

Based on information from interviews conducted and records reviewed, although the allegation listed above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED.

No Deficiencies cited under California Code of Regulations Title 22.

This report was reviewed with Administrator, Merle Laurel, and a copy of this report provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Steve Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2