<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202423
Report Date: 11/09/2024
Date Signed: 11/12/2024 09:56:23 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/08/2023 and conducted by Evaluator Jason Lund
COMPLAINT CONTROL NUMBER: 26-AS-20230808145034
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: 14DATE:
11/09/2024
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Staff Alex IgnacioTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff physically abused resident

Staff neglected resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Jason Lund arrived unannounced to complete a complaint investigation regarding the above allegations. LPA Lund met with Staff Alex Ignacio and explained the reason for the visit. Administrator Merle Laurel could not make the visit today and gave permission for staff Alex Ignacio to sign the required paperwork. Census: 14
Staff physically abused resident - LPA Lund reviewed facility records, San Jose Police report-SJ 2023-232160140, interviewed staff, and residents in care. Based on facility records review, San Jose Police report-SJ 2023-232160140, interviews with staff, and residents in care. According to San Jose Police report-SJ 2023-232160140 on 8/2/2023 Resident (R1) was pushed by a suspect (Staff) from the back, into the residents’ room. R1 was pushed approximately 20 times from the back supposed staff.
Unsubstantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2024
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-20230808145034
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: LAUREL HAVEN
FACILITY NUMBER: 435202423
VISIT DATE: 11/09/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
On 8/2/2023 R1 called 911 to go to the ER. On 8/4/2023 San Jose police officer interviewed R1 regarding the incident on 8/2/2023. San Jose police officer interviewed case manager, Administrator Merle Laurel, and care staff from the facility. Case manager for R1 stated to the officer that R1 would not be going back to the facility and would find new housing. Functional Capability Assessment dated 7/14/2023 states that R1 loses balance easily which leads to R1 falling. Doctor recommended that R1 use a walker to help with walking. Staff stated to LPA Lund that R1 would refuse to use the walker. San Jose Police report-SJ 2023-232160140- States that no injuries completed.
Based on facility records review, San Jose Police Report-SJ 2023-232160140, interviews with staff, and residents in care on the information provided, it was unclear if staff physically abused resident, therefore the allegation was deemed UNSUBSTANTIATED.
Staff neglected resident - LPA Lund reviewed facility records, San Jose Police report-SJ 2023-232160140, interviewed staff, and residents in care. Based on facility records review, San Jose Police report-SJ 2023-232160140, interviews with staff, and residents in care. Resident (R1) was placed at the facility on 7/14/2023 and Functional Capability Assessment dated 7/14/2023 states that R1 loses balance easily which leads to R1 falling. Staff interviewed stated that they would continually remind R1 to use walker and on 8/2/203 R1 called 911 to go to the ER. On 8/4/2023 San Jose police officer interviewed R1 regarding the incident on 8/2/2023. San Jose police officer interviewed case manager, Administrator Merle Laurel, and care staff from the facility. Case manager for R1 stated to the officer that R1 would not be going back to the facility and would find new housing. Residents interviewed stated that staff treat well and here to help them when needed. San Jose Police report-SJ 2023-232160140- States that no injuries completed.
Based on facility records review, San Jose Police report-SJ 2023-232160140, interviews with staff, and residents in care on the information provided, it was unclear if staff neglected resident, therefore the allegation was deemed UNSUBSTANTIATED.
As a result of this investigation, this Department finds the allegation to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted and report left.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2