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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202424
Report Date: 09/13/2023
Date Signed: 09/13/2023 04:32:08 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 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
05/28/2020 and conducted by Evaluator Manuel Monter
COMPLAINT CONTROL NUMBER: 26-AS-20200528112506
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:
09/13/2023
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Administrator SamonteTIME COMPLETED:
04:35 PM
ALLEGATION(S):
1
2
3
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5
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7
8
9
Unlawful Eviction
INVESTIGATION FINDINGS:
1
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3
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7
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9
10
11
12
13
LPA Monter conducted an unannounced visit to deliver findings of the above allegation. Met with Administrator(ADM) Samonte. On 06/05/2020, the Department conducted an initial investigation/inspection wherein copies of resident's (R1) files were reviewed and obtained.

Unlawful Eviction:
On 7/26/2023, the Department conducted subsequent interview with Administrator (ADM). ADM stated that R1 was not illegally evicted. ADM stated that it was an interdisciplinary decision to relocate R1 to a higher level of care facility. ADM stated R1's responsible party or power of attorney including medical professional from Onlok determined based on R1's assessment he/she requires a higher level of care. R1 was admitted to the hospital. ADM stated that after R1 hospitalization, he/she was reassessed and deemed need to be transferred to Rehab due to weakness.

Page 1 of 2.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023
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 4
Control Number 26-AS-20200528112506
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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: CASA LAUREL
FACILITY NUMBER: 435202424
VISIT DATE: 09/13/2023
NARRATIVE
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ADM stated that R1's mobility became harder including food intake due to swallowing issue. ADM stated that R1's responsible party was actively involved and well informed about R1's care needs including his/her relocation.

On 06/05/2020, the Department interviewed Administrator (ADM). ADM stated that R1 declined in mobility functionality due to weakness on right foot and left leg was giving out due to stroke. ADM stated that on 05/31/2020, 911 was called because R1 was observed drooling and facial drooping. ADM stated that R1 sent to the hospital and was seen by Physical Therapy wherein R1 was not able to bear weight which happened the previous week. ADM stated, "we don’t really want to put her/him at risk in terms of standing her/him up." ADM stated, "we were lifting her/him up.. even me, it is pretty much dead weight.... it was requiring two people to lift him/her up.."

ADM stated that when R1 was discharged from the hospital, R1's responsible party was adamant about sending R1 to skilled nursing facility. ADM stated R1's care was discussed with his/her responsible party since last year (2019) that the facility may not be able to handle R1's care. ADM stated that R1's PCP agreed that R1 needs to go to short term rehabilitation to build up her/his stamina maybe and the family wants to bring her back.

On 09/06/2023, the Department received a response from R1's social worker from Onlok to state, " I am writing to confirm that at the time of R1's hospitalization, it was determined that he/she needed a higher level of care following that hospitalization. R1 was then placed at a Skilled Nursing Facility."

The Department has completed the investigation of the above allegations. Based on interviews conducted and record review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

No deficiencies cited, Exit interview conducted with Administrator Samonte, and a copy of this report provided. Staff member Eluminada Yap signed on ADM's behalf.

Page 2 out of 2, End of Report
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 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
05/28/2020 and conducted by Evaluator Manuel Monter
COMPLAINT CONTROL NUMBER: 26-AS-20200528112506

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:
09/13/2023
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Administrator SamonteTIME COMPLETED:
04:35 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility Staff did not follow prescribed medical services
Facility staff did not clip resident's toe nails
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
LPA Monter conducted an unannounced visit to deliver findings of the above allegation. Met with ADM Samonte. On 06/05/2020, the Department conducted an initial investigation/inspection wherein copies of resident's (R1) files were reviewed and obtained.

Facility staff did not follow prescribed medical services

On 7/26/2023, the Department conducted subsequent interview with Administrator (ADM). ADM stated that R1 did not have a physical therapy order nor a home health services. ADM stated that staff conducted range of motion exercises wherein R1 was able to raise his/her upper legs and able to kick. ADM stated that one of R1's responsible party not his/her power of attorney demand R1 to walk but R1 was unable to walk but in contrary R1's power of attorney had instructed staff not to let R1 out of its cold outside. R1 was passive but able to ambulate with assistance.
Page 1 of 2
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 26-AS-20200528112506
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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: CASA LAUREL
FACILITY NUMBER: 435202424
VISIT DATE: 09/13/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
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On 09/13/2023 LPA Monter interviewed facility staff. 2 out of 2 staff stated R1's did receive physical therapy back in 2020, but don't remember exactly as it was a long time ago.

Facility staff did not clip resident's toenails.

On 7/26/2023, the Department conducted subsequent interview with Administrator (ADM) on the phone.
ADM stated that staff at the facility are not allowed to clip R1's or other residents' toenails. ADM stated that R1's case manager was informed about R1's toenails. ADM stated that R1's other responsible did mention to them about R1's toenails but he/she was informed about their disposition. ADM stated, "What's long for him/her is not long for us." ADM stated that R1 was seen by case manager (CM1). CM1 was aware of R1's toenails. ADM stated that the R1's responsibility party/power of attorney was aware about this complaint allegation, and it was discussed with him/her.

On 06/05/2020, the Department interviewed Administrator (ADM) regarding R1's toenails. ADM stated, " no, we do not cut toe nails, we take them to their doctor or the doctor at their clinic does that. I used to have a podiatrist who comes to the house, but they retired now. " ADM stated that R1 would go every three months... the last time she/he went to get his/her nails clipped was in March. That is when they stopped everyone going to the clinic. She hasn’t gone then since the clinic is closed. Basic services does not cover toe nail clipping. There was nothing in R1's Admission Agreement about toe nail cutting."

On 09/13/2023 LPA Monter interviewed 2 residents regarding the allegation. 2 out of 2 residents stated they have not seen other residents with long toenails. R2 stated the facility will take him/her to the podiatrist to get her toenails trimmed every 2 months. 1 resident did not want to be interviewed. 1 resident was not interviewed due to language barrier. Staff stated R1's roommate does not live in the facility.

LPA interviewed 2 staff regarding the allegation. Both staff interviewed stated the facility does not cut the residents toenails, the podiatrist does that.

Based on the interviews conducted, observation and records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4