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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202424
Report Date: 07/17/2024
Date Signed: 07/17/2024 04:00:03 PM

Document Has Been Signed on 07/17/2024 04:00 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:CASA LAURELFACILITY NUMBER:
435202424
ADMINISTRATOR/
DIRECTOR:
SOL SAMONTEFACILITY TYPE:
740
ADDRESS:680 NORTH 18TH ST.TELEPHONE:
(408) 287-4541
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY: 6CENSUS: 5DATE:
07/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Merle LaurelTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Administrator (ADM) Merle Laurel.

During visit, LPA Marrufo toured the facility inside and out. LPA toured the kitchen area and food storage areas and 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 observed there to be a locked cabinet for storage of cleaning supplies and sharp objects. LPA observed the first aid kit and found it to be complete.

LPA toured 4 out of 4 resident bedrooms. Each bedroom had available bedding and clothing storage areas as well as working lights. LPA tested the smoke detectors in the hallways, living room, and 4 out of 4 bedrooms. The smoke detector in the hallway and in 1 on the 4 resident rooms had a very faint sound when tested. The rest of the smoke detectors functioned properly when tested. 1 out of 1 carbon monoxide detectors functioned properly when tested. LPA toured 2 out of 2 resident bathrooms and observed each bathroom to have available soap and paper towels and working lights. The water temperatures in the bathroom sinks measured at 110 F and 111 F. The last recorded Emergency Disaster Drill was conducted on 07/01/2024.

LPA toured the outside area and found the outdoor exits were clear of obstructions. LPA reviewed the Centrally Stored Medication and Destruction Records and resident records for 5 out of 5 residents and found them to be complete. LPA reviewed 3 out of 3 staff records and found them to be complete.

No deficiencies were cited at this time as per California Code of Regulations Title 22. An Advisory Note was issued. See LIC9102 for more information. This report was reviewed with ADM Merle Laurel and a copy of this report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 07/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/17/2024
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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