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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202423
Report Date: 04/25/2024
Date Signed: 04/25/2024 11:32:58 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 04/25/2024 11:32 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:LAUREL HAVENFACILITY NUMBER:
435202423
ADMINISTRATOR/
DIRECTOR:		TERESITA SAMONTEFACILITY TYPE:
740
ADDRESS:1157 SOUTH SIXTH ST.TELEPHONE:
(408) 287-5074
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY: 15CENSUS: 13DATE:
04/25/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Merle LaurelTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management - Annual Continuation visit and met with Merle Laurel. LPA visited the facility to continue the annual inspection visit that began on 01/30/2024.

During visit, LPA Marrufo inspected the water temperatures in 3 out of 3 resident bathrooms. The water temperatures were 119 F, 118 F, and 116.5 F.

LPA Marrufo reviewed Centrally Stored Medication Logs and resident records for 5 residents and found them to be complete. LPA reviewed staff records and found them to be complete. LPA Marrufo reviewed the Emergency Disaster Drill Log and found the last drill occurred on 04/03/2024.

LPA Marrufo reviewed 1 out of 1 Personal and Incidental Money Log and found it to be complete.

No deficiencies were cited at this time as per California Code of Regulations Title 22.

This report was reviewed with Merle Laurel and a copy of this report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2024
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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