435202422-3-26-2025-26-AS-CKAI-DF5P4W-20250326105948

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202422
Report Date: 03/26/2025
Date Signed: 03/26/2025 11:00:07 AM

Document Has Been Signed on 03/26/2025 11:00 AM - 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 HEIGHTS		FACILITY NUMBER:	435202422
ADMINISTRATOR/ DIRECTOR:	NENITA ABAD		FACILITY TYPE:	740
ADDRESS:	17340 OAK LEAF DR.		TELEPHONE:	(408) 778-4803
CITY:	MORGAN HILL	STATE: CA	ZIP CODE:	95037
CAPACITY: 6		CENSUS: 6	DATE:	03/26/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:15 AM
MET WITH:	Nenita Abad		TIME VISIT/ INSPECTION COMPLETED:	11:05 AM

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) Christine Kabariti arrived unannounced to conduct the facility's required 1 year annual inspection. LPA met with Administrator (ADM), Nenita Abad. During visit, LPA toured the facility with ADM to include the living room, dining room, kitchen, 2 staff bedrooms, garage, 3 resident bedrooms, 3 bathrooms and exterior. All fire exit routes were free and clear of obstruction. All staff present are fingerprint cleared and associated to the facility. Facility temperature maintained at 68 degrees F. Kitchen is equipped with at least 2 days worth of perishables and 7 days worth of non-perishable foods. Medications, sharp objects, chemicals and disinfectants observed locked. Refrigerator temperature maintained at 30 degrees F and freezer temperature maintained at 0 degrees F. Men's bathroom hot water temperature maintained at 111 degrees F. Women's bathroom hot water temperature maintained at 112.4 degrees F. Resident bedrooms equipped with beds, linens, dressers, night stand and adequate lighting. Sliding doors and screen doors observed well maintained. Fire extinguisher last serviced on 1/3/2025. Carbon monoxide detector observed operable. 3 resident records were reviewed and observed complete. 3 residents medications and centrally stored medication records were reviewed and all medications were accounted for. Facility has a PRN medication log for each resident. See LIC809-C.

NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
	VISIT DATE: 03/26/2025

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3 staff records were reviewed. 2 out of 3 staff has an active first aid certification. 3 out of 3 staff has a health screening, TB result, fingerprint clearance, and training. LPA advised ADM to ensure the amount of training hours completed is stated on the staff training record.

Facility has an emergency disaster plan. Disaster drills are being conducted monthly and the the drill was completed in February 2025. LPA advised to include the names of the staff and residents (if applicable), who were part of the disaster drill on the drill log per Health and Safety Code Section 1569.695(c). LPA observed the facility has flash lights and batteries. Facility is equipped with a first aid kit. LPA did not observe the facility has any band-aids or roller bandages. ADM stated a plan to place an order for band-aids or roller bandages today.

Documents were requested by 04/04/2025 to include: LIC500, LIC308, liability insurance, qualifications of administrator (certificate), lease agreement, emergency disaster plan, LIC200 (if applicable). LPA advised ADM to review the facility's program plan for updates and to submit the updated program plan to Licensing for review.

No deficiencies were cited per California Code of Regulations, Title 22. Advisory note provided. This report was reviewed with Administrator, Nenita Abad and a copy of the report was provided.

NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2025

LIC809 (FAS) - (06/04)

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