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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202461
Report Date: 09/28/2024
Date Signed: 09/28/2024 04:07:01 PM

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
08/30/2023 and conducted by Evaluator Simranjit Rai
COMPLAINT CONTROL NUMBER: 26-AS-20230830135123
FACILITY NAME:LAUREL LODGEFACILITY NUMBER:
435202461
ADMINISTRATOR:MERLE M. LAURELFACILITY TYPE:
740
ADDRESS:2247 SERRA AVE.TELEPHONE:
(408) 260-6880
CITY:SANTA CLARASTATE: CAZIP CODE:
95050
CAPACITY:6CENSUS: 5DATE:
09/28/2024
UNANNOUNCEDTIME BEGAN:
03:25 PM
MET WITH:House Manager, Eugene (Eugenio) De LeonTIME COMPLETED:
03:50 PM
ALLEGATION(S):
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Facility staff hit a resident.
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 (Eugenio) De Leon and stated the purpose of the visit.

On 8/30/2023, the Department received a complaint with the above allegation. On 9/8/2023, the Department conducted the initial investigation.

On 9/8/2023, LPA Rai conducted interviews with 3 staff members (S1-S3). Three out of three staff members understand the facility policy about physical abuse and they have not seen or hit any of 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: 09/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2024
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-20230830135123
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: 09/28/2024
NARRATIVE
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Page 2 of 2.

On 9/8/2023, LPA Rai conducted interviews with 4 residents (R1-R4). Four out of four residents stated they have not seen facility staff hit a resident. R1 stated he/she has not seen or heard the staff hitting the residents. R1 stated the facility staff hit one of the residents but was not able to further explain when this incident occurred, and which staff hit which resident. R1 stated “he/she does not know” which staff are hitting the residents.

Based on record review of R4’s Physician’s Report dated 7/20/2021 which stated R4 has a mental health condition which may have hallucinations, delusions and manic episodes. Based on review of R4’s Needs and Services Plan dated 1/1/2023, R4 is preoccupied with self-thoughts and talking and has loud outburst at times which may not be "redirectable".

Based on the interviews and record review, although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the above allegation 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 (Eugenio) De Leon and a copy of the report was provided.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2