435202461-12-19-2023-26-AS-RMAO-CYWLA2-20231227073426

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202461
Report Date: 12/19/2023
Date Signed: 12/19/2023 09:15:26 AM

Unsubstantiated

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
08/08/2023 and conducted by Evaluator Simranjit Rai

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20230808090908

FACILITY NAME:	LAUREL LODGE		FACILITY NUMBER:	435202461
ADMINISTRATOR:	MERLE M. LAUREL		FACILITY TYPE:	740
ADDRESS:	2247 SERRA AVE.		TELEPHONE:	(408) 260-6880
CITY:	SANTA CLARA	STATE: CA	ZIP CODE:	95050
CAPACITY:	6	CENSUS: 6	DATE:	12/19/2023
		UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	House Manager, Eugene Deleon		TIME COMPLETED:	09:25 AM

ALLEGATION(S):

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Facility staff yell at the residents

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with House Manager, Eugene Deleon and stated the purpose of the visit.

On 8/8/2023, the Department received a complaint with the above allegation. On 8/17/2023 the Department conducted the initial investigation.

On 8/17/2023, the Department conducted an initial investigation visit at the facility and interviews with 3 staff members, S1-S3. 3 Out of 3 staff stated they have not observed, nor do they yell at the residents. S2 stated R1 will hit the staff and R1 becomes paranoid. S2 stated the staff know the policy on not yelling or hitting the residents.

Continuation on LIC 9099-C, Page 1 of 2.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023

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 7

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
08/08/2023 and conducted by Evaluator Simranjit Rai

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20230808090908

FACILITY NAME:	LAUREL LODGE		FACILITY NUMBER:	435202461
ADMINISTRATOR:	MERLE M. LAUREL		FACILITY TYPE:	740
ADDRESS:	2247 SERRA AVE.		TELEPHONE:	(408) 260-6880
CITY:	SANTA CLARA	STATE: CA	ZIP CODE:	95050
CAPACITY:	6	CENSUS: 6	DATE:	12/19/2023
		UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	House Manager, Eugene Deleon		TIME COMPLETED:	09:25 AM

ALLEGATION(S):

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Facility staff restrict resident's access to telephones.
Facility does not provide transportation to dental appointments.
Facility provides dinner at 3:15pm.
Facility requires residents to provide their own toliet paper.
Facility does not provide comfortable temperature.
Facility does not provide safe and comfortable furnishings

INVESTIGATION FINDINGS:

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Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023

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 7

Control Number 26-AS-20230808090908

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: LAUREL LODGE	FACILITY NUMBER: 435202461
	VISIT DATE: 12/19/2023

NARRATIVE

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Page 2 of 5.
Facility staff restrict resident's access to telephones.
On 8/17/2023, the Department conducted an initial investigation visit at the facility. LPA Monter observed the facility phone next to the fridge. LPA called his work phone using the facility phone and the phone call connected.

LPA Monter conducted interviews with 3 staff members, S1-S3. 3 Out of 3 staff stated there is a phone in the facility for residents to use and its located next to the refrigeration with no restrictions. 2 Out of the 3 residents use the facility phone.

LPA Monter conducted interviews with 6 residents, R1-R6. 6 Out of 6 residents stated there is a telephone in the facility for residents to use. 4 Out of 6 residents know the location of the telephone which is next to the refrigerator in the kitchen.

R1 stated the facility will not let R2 call 911. Based on record review of R2’s Physician’s Report and Needs and Services plan, its stated R2 has severe paranoia, and the facility staff are observing R2 and provide reassurance at all times. R2 stated the facility will let him/her use the phone to call family members and case manager. R2 stated he/she needs to talk to TV stations or radio stations to get mad at them.

Facility does not provide transportation to dental appointments.
LPA Monter conducted interviews with 3 staff members, S1-S3. 3 Out of 3 staff stated the resident’s case manager will take the residents to their doctor/dental appointments. S1 stated he/she will take the residents to their doctor/dental appointments. S1 stated the facility may call an Uber for the residents to transport them as well.

LPA Monter conducted interviews with 6 residents, R1-R6. 6 Out of 6 residents stated the facility will provide transportation to take resident to the medical or dental appointments.

Based on review of R1-R3’s Admission Agreement, the facility marked “Plan, arrange, and/or provide for transportation to medical and dental appointments”, which indicates the facility will provide this service to the resident.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 7

Control Number 26-AS-20230808090908

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: LAUREL LODGE	FACILITY NUMBER: 435202461
	VISIT DATE: 12/19/2023

NARRATIVE

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Page 3 of 5.
Facility provides dinner at 3:15pm.
On 8/17/2012, the Department conducted an initial investigation visit and LPA Monter conducted interviews with 3 staff members, S1-S3. 3 Out of 3 staff stated they provide meals in a timely manner and provide snacks after dinner if residents are still hungry. S1 stated they provide fruits ad cookies as snacks to the residents. S2 stated they will provide juice, fruit or biscuits for residents after dinner.

LPA Monter conducted interviews with 6 residents, R1-R6. R1 stated dinner is provided early at 4:15pm, but snacks such as fruit is always provided and available in the kitchen. 5 out of 6 residents stated dinner is provided on time between 4:30-5:00pm.

Based on record review of facility’s Program Plan, breakfast is served at 8:00am, lunch is served at 12:00pm, dinner is served at 5:00pm and snack is provided at 8:00pm. It’s also stated that snacks will be provided and served in between meals.

Facility requires residents to provide their own toliet paper.
On 8/17/2023, the Department conducted an initial investigation visit at the facility. LPA Monter toured the residents’ rooms. LPA observed toilet paper in all residents’ bathrooms. LPA also observed a stockpile of toilet paper in the facility garage.

LPA Monter conducted interviews with 3 staff members, S1-S3. 3 Out of 3 staff stated the facility provides toiletries.

LPA Monter conducted interviews with 6 residents, R1-R6. 6 Out of 6 residents stated the facility provides toilet paper and the residents do not need to buy their own toilet paper.

Based on review of R1-R3’s Admission Agreement, the facility marked “Hygiene items of general use, such as soap and toilet paper will be provided by the facility”, which indicates the facility will provide this service to the residents.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 7

Control Number 26-AS-20230808090908

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: LAUREL LODGE	FACILITY NUMBER: 435202461
	VISIT DATE: 12/19/2023

NARRATIVE

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Page 4 of 5.
Facility does not provide comfortable temperature.
On 8/17/2023, the Department conducted an initial investigation visit at the facility. LPA Monter measured the facility kitchen area as 78 degrees F. LPA Rai observed air conditioning unit in living room was running and several fans as well.

LPA Monter conducted interviews with 3 staff members, S1-S3. 3 Out of 3 staff stated the facility keeps the residents cool by turning on the AC and then turning on the fans as well.

LPA Monter conducted interviews with 6 residents, R1-R6. 6 Out of 6 residents stated the facility does keep the residents cool by providing fans and air conditioning in the living room. 2 Out of 6 residents stated the facility will provide cold water if the weather gets too hot.

Based on Weather.com, the weather report for the city of Santa Clara during the visit was the average of 81 degrees.

Facility does not provide safe and comfortable furnishings
On 8/17/2023, the Department conducted an initial investigation visit at the facility. LPA Monter observed the residents’ bedrooms and mattresses. LPA did not observe furnishings and or mattresses in disrepair.

LPA Monter conducted interviews with 3 staff members, S1-S3. 3 Out of 3 staff stated the facility provides the mattresses for the residents and the facility owner will get new mattresses and will replace it.

LPA Monter conducted interviews with 6 residents, R1-R6. 6 Out of 6 residents facility provided comfortable furniture. R1 stated facility provide the mattress and his/her conservator would help getting a new mattress.

Based on review of R1-R3’s Admission Agreement, the facility marked “comfortable and suitable bed and bedroom furniture will be provided by the facility”, which indicates the facility will provide comfortable furnishings to the residents.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023

LIC9099 (FAS) - (06/04)

Page: 6 of 7

Control Number 26-AS-20230808090908

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: LAUREL LODGE	FACILITY NUMBER: 435202461
	VISIT DATE: 12/19/2023

NARRATIVE

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Page 5 of 5.

The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, 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 from California Code of Regulations, Title 22. Exit interview conducted with House Manager, Eugene Deleon and a copy of the report was provided.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023

LIC9099 (FAS) - (06/04)

Page: 7 of 7

Control Number 26-AS-20230808090908

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: LAUREL LODGE	FACILITY NUMBER: 435202461
	VISIT DATE: 12/19/2023

NARRATIVE

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Page 2 of 2.

LPA Monter conducted interviews with 6 residents, R1-R6. R1 stated the facility staff yell the resident but he/she has not witnessed the staff yelling the resident and no one else has witnessed the staff yelling. R2 stated the staff yell at him/her because he/she is a “telepathist and revolutionary”. Based on record review of R2’s Physician’s Report and Needs and Services plan, its stated R2 has severe paranoia, and the facility staff are observing R2 and provide reassurance at all times.

Based on Physician’s Reports, 6 Out of 6 residents have mental disorders which may skew their understanding of facility staff using a louder voice as yelling to the residents.

Based on the interviews, observation, and record 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.

No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with House Manager, Eugene Deleon and a copy of the report was provided.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 7