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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202422
Report Date: 03/10/2022
Date Signed: 03/10/2022 04:56:27 PM

Document Has Been Signed on 03/10/2022 04:56 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:LAUREL HEIGHTSFACILITY NUMBER:
435202422
ADMINISTRATOR:NENITA ABADFACILITY TYPE:
740
ADDRESS:17340 OAK LEAF DR.TELEPHONE:
(408) 778-4803
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY: 6CENSUS: 6DATE:
03/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:25 PM
MET WITH:Nenita AbadTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Christine Dolores conducted an unannounced annual required inspection and met with Administrator Nenita Abad.

During visit, LPA toured the facility inside and outside to include the central entry point, bathrooms, resident rooms, living room, dining room, kitchen, and backyard. All exit routes were free and clear of obstruction.

Bathrooms observed to be supplied with hygiene products and paper supplies. Hand washing signs were posted in bathrooms. Trash can was observed with lid. Hand sanitizer available to residents and visitors. LPA observed supply of Personal Protective Equipment (PPE). All staff observed to be wearing a face mask. The following posters were observed to include visitors sign, wash your hands, and social distancing. Facility disinfect and sanitize high touch surfaces daily and as needed.

During visit, LPA advised facility to create a PPE supply cart and to review facility's mitigation plan in regards to screening, isolating, quarantine, testing, cleaning, and disinfecting. LPA will provide Administrator COVID-19 resources.

At 03:41 p.m., LPA observed the screen door in the resident's room to not slide open and close easily. At 03:46 p.m., LPA observed a screen door in the kitchen area unattached and leaning against the wall.

A deficiency cited per California Code of Regulations, Title 22. Advisory note provided.

This report was reviewed with Administrator Nenita Abad and a copy of this report and appeal rights was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2022
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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Document Has Been Signed on 03/10/2022 04:56 PM - It Cannot Be Edited


Created By: Christine Dolores On 03/10/2022 at 04:29 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: LAUREL HEIGHTS
FACILITY NUMBER: 435202422

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303
(c) All window screens shall be clean and maintained in good repair.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above by not ensuring window screen in resident's room can open and close easily and screen door in kitchen to be in disrepair which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/17/2022
Plan of Correction
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Licensee will repair window screen in resident's room and window screen in the kitchen area by following-up with the repair man to repair window screens. Licensee will send LPA plan of correction by 03/17/2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Jackie Jin
LICENSING EVALUATOR NAME:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2022


LIC809 (FAS) - (06/04)
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