<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202422
Report Date: 03/24/2024
Date Signed: 03/24/2024 12:43:13 PM


Document Has Been Signed on 03/24/2024 12:43 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: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:
03/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Administrator Nenita AbadTIME COMPLETED:
12:50 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator (ADM) Nenita Abad. During the visit, LPA observed 6 residents and 2 staff.

LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room, 3 restrooms and 3 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. There was no obstruction to block the walkways. While touring resident bedroom #3's private bathroom, LPA observed a laundry detergent container, with the name "Lysol." (Photographs were taken.) ADM stated the laundry detergent belongs to R4 and forgot to put it back in the garage. (Note: bedroom #3 is a shared bedroom for R4 and R5.)

Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 70 degrees F. LPA measured hot water temperature with a thermometer in all 3 facility bathrooms and water temperature was measured to range from 138-139 degrees F. (LPA took photos and videos of thermometer)

Fire extinguisher was serviced in January 24, 2024. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on February 12, 2024.

LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA conducted interviews with 1 staff and 2 residents.

Deficiencies are being cited during today's visit. This report was reviewed with Administrator (ADM) Nenita Abad and a copy of the signed report was provided. Appeal Rights were provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 03/24/2024 12:43 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 HEIGHTS
FACILITY NUMBER: 435202422

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and LPA's measurement with a thermometer, the licensee did not comply with the section cited above. 3 Out of 3 bathrooms water temperature was measured to range from 138-139 degrees F. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2024
Plan of Correction
1
2
3
4
ADM agrees to submit a Plan of Correction by POC date to ensure that water temperatures in the sinks of all resident bathrooms are between 105 F to 120 F. ADM shall submit video evidence to CCL once bathroom sink temperatures are corrected.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 03/24/2024 12:43 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 HEIGHTS
FACILITY NUMBER: 435202422

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. While touring resident bedroom #3's private bathroom, LPA observed a laundry detergent container, with the name "Lysol", accessible to residents R4 and R5. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2024
Plan of Correction
1
2
3
4
ADM stated she will send a written plan of action stating how she will ensure disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger are stored inaccessible to residents in care. ADM stated she will send the plan of action by POC date, 03/29/2024.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3