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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202423
Report Date: 02/13/2025
Date Signed: 02/21/2025 03:14:36 PM

Document Has Been Signed on 02/21/2025 03:14 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: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: 15DATE:
02/13/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Merle LaurelTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Administrator Merle Laurel.

During visit, LPA Marrufo toured the facility inside and out. LPA toured the kitchen area and food storage areas. LPA observed there to be a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA reviewed the first aid kit and found it to be complete.

LPA toured the facility and tested the smoke detectors in the hallways and each resident room. All smoke detectors functioned properly when tested. The carbon monoxide detector functioned properly when tested. LPA toured each resident room and found each room to have functioning lights and available bedding and clothing storage areas.

LPA toured three out of three resident bedrooms. Each bedroom had available soap and hand drying machines as well as working lights. The water temperatures in the bathroom sinks were 116 F - 118 F.

LPA toured the outside area and found the exits to be clear of obstructions.

LPA reviewed six resident records and six Centrally Stored Medication and Destruction Records and found them all to be complete. LPA reviewed five staff records and found them to be compete.

The Disaster Drill Log indicates the last drill was conducted on February 1st, 2025.

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

This report was reviewed with Administrator Merle Laurel and a copy of this report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2025
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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