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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202424
Report Date: 06/14/2022
Date Signed: 06/14/2022 03:45:45 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
06/08/2022 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20220608170134
FACILITY NAME:CASA LAURELFACILITY NUMBER:
435202424
ADMINISTRATOR:SOL SAMONTEFACILITY TYPE:
740
ADDRESS:680 NORTH 18TH ST.TELEPHONE:
(408) 287-4541
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY:6CENSUS: 5DATE:
06/14/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Merle LaurelTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
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4
5
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8
9
Facility staff is not properly administering resident medications
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation initial visit and met with Merle Laurel.

During visit, LPA Marrufo interviewed residents R1 and R3-R5. Resident R2 did not want to be interviewed. LPA Marrufo interviewed staff S1-S2 and Licensee Merle Laurel. LPA Marrufo reviewed resident records, including medication records. LPA Marrufo conducted a medication audit using the Medication Administraition Record with S1 for residents R1-R5. LPA Marrufo did not observe any errors with the amount of remaining medications for any resident.

4 out of 4 interviewed residents stated to have not experienced staff administering the wrong medications to them. 2 out of 2 interviewed staff stated to have not administered the wrong medications to residents.

See LIC9099-C for more information. Page 1 of 2.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022
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-20220608170134
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: CASA LAUREL
FACILITY NUMBER: 435202424
VISIT DATE: 06/14/2022
NARRATIVE
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LPA Marrufo reviewed and obtained copies of the Resident Log In/Out Record, which indicates resident R1 logged out of the facility on 05/24, 26-31/2022 and 06/01/2022; and R4 logged out of the facility 06/01/2022 and 06/14/2022.

Based on information from interviews conducted with staff and residents, 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 allegation is unsubstantiated.

No Deficiencies cited under California Code of Regulations Title 22

This report was reviewed with Merle Laurel and a copy of the report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2