435202461-9-28-2024-26-AS-RMAO-D9VUGS-20241009153449

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202461
Report Date: 09/28/2024
Date Signed: 09/28/2024 04:07:50 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
10/03/2023 and conducted by Evaluator Simranjit Rai

COMPLAINT CONTROL NUMBER: 26-AS-20231003112700

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: 5	DATE:	09/28/2024
		UNANNOUNCED	TIME BEGAN:	03:50 PM
MET WITH:	House Manager, Eugene (Eugenio) De Leon		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Facility staff not following medication order as prescribed by physician.

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 10/3/2023, the Department received a complaint with the above allegation. On 10/12/2023, the Department conducted the initial investigation.

On 10/12/2023, the Department conducted interviews with 3 staff members, S1-S3. 3 Out of 3 staff members stated they are following doctor’s orders and administering medication.

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

Unfounded

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 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
10/03/2023 and conducted by Evaluator Simranjit Rai

COMPLAINT CONTROL NUMBER: 26-AS-20231003112700

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:	DATE:	09/28/2024
		UNANNOUNCED	TIME BEGAN:	03:50 PM
MET WITH:	House Manager, Eugene (Eugenio) De Leon		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Facility is not kept clean and free of rodents, vermin and insects.
Facility staff is not according dignity to resident by saying sexual innuendos.

INVESTIGATION FINDINGS:

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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: 2 of 4

Control Number 26-AS-20231003112700

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.

Facility is not kept clean and free of rodents, vermin and insects.
On 10/12/2023, the Department conducted interviews with 3 staff members, S1-S3. 3 Out of 3 staff members stated they clean the facility and ensure the facility is free of rodents, vermin, and insects.

On 10/12/2023, the Department conducted interviews with 4 residents, R1-R4. 4 Out of 4 residents stated the facility staff clean the facility and the facility does not have rodents, vermin, and insects.

During visit on 10/12/1023, LPA observed the kitchen, living room and 4 staff bedrooms and 2 bathrooms and the areas were clean and free of rodents, vermin, and insects.

Facility staff is not according dignity to residents by saying sexual innuendoes.
On 10/12/2023, the Department conducted interviews with 3 staff members (S1-S3). Three out of three staff stated they speak with respect to the residents, and they do not use or saying any sexual phrases to the residents. Three out of three staff stated they

have not seen or heard staff or residents saying “sexual innuendoes” to residents at the facility. Three out of three residents stated they are trained in residents rights, and they are able to state at least 4 residents rights in a licensed facility.

On 10/12/2023, the Department conducted interviews with 4 residents, R1-R4. 4 Out of 4 residents they did not hear any staff or residents say “sexual innuendoes” to residents at the facility.

Based on the interviews conducted with residents and staff and based on 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.

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: 3 of 4

Control Number 26-AS-20231003112700

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 10/12/2023, the Department conducted interviews with 4 residents, R1-R4. 4 Out of 4 residents stated they are given medication as the doctor has prescribed it to them. 4 Out of 4 residents stated the facility staff follow up on medications when they need to be refilled.

Based on record review of R5’s Medication Administration Record (MAR) for August 2023, September 2023 and October 2023, medications were administered to the resident as indicated by staff initials on each dose.

The Department has completed the investigation of the above allegation. Based on interviews conducted and record reviews, the department has found that the above allegation were UNFOUNDED, meaning that the allegation 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 (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: 4 of 4