435202423-10-26-2024-26-AS-KHOS-DARR77-20241106114552

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202423
Report Date: 10/26/2024
Date Signed: 10/26/2024 05:09:45 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/14/2022 and conducted by Evaluator Jason Lund

COMPLAINT CONTROL NUMBER: 26-AS-20220714111842

FACILITY NAME:	LAUREL HAVEN		FACILITY NUMBER:	435202423
ADMINISTRATOR:	TERESITA SAMONTE		FACILITY TYPE:	740
ADDRESS:	1157 SOUTH SIXTH ST.		TELEPHONE:	(408) 287-5074
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95112
CAPACITY:	15	CENSUS: 14	DATE:	10/26/2024
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Administrator Merle Laurel		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Resident has scabies
Staff misplaced resident’s medication
Staff failed to keep facility free of pests
Facility restrains residents in their bedrooms

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to complete a complaint investigation regarding the above allegations. LPA Lund met with Administrator Merle Laurel and explained the reason for the visit. Census: 14

Resident has scabies - LPA Lund reviewed facility records, interviewed staff, and residents in care. Based on reviewed facility records, interviews with staff, and residents in care. LPA Lund reviewed Residents (R1) Medication Administration Records (MARS) from 5/1/2022 through 8/30/2022. In 6/1/2022 through 6/18/2022 R1 was prescribed a cream but never used it. Staff interviewed stated that the facility never had scabies. Residents interviewed stated that they have never had scabies. On 7/22/2022 LPA David Marrufo observed that the facility didn't have scabies.

Unsubstantiated

Estimated Days of Completion: 90

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2024

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 3

Control Number 26-AS-20220714111842

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: LAUREL HAVEN	FACILITY NUMBER: 435202423
	VISIT DATE: 10/26/2024

NARRATIVE

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Based on facility records review, interviews with residents and staff on the information provided, it was unclear if resident has scabies, therefore the allegation was deemed UNSUBSTANTIATED.

Staff misplaced resident’s medication - LPA Lund reviewed facility records, interviewed staff, and residents in care. Based on facility records indicate that staff have had the six-hour Medication Training Program. Four hours of initial instruction & 2 hours of hands-on shadowing. LPA reviewed Medication Administration Records (MARS) from residents in care from May 2022 through August 2022 and were in compliance. Staff interviewed stated most residents take their medications when told, if not we come back to them. If a resident doesn’t take their medication, we mark in their Medication Administration Records (MARS) and notify parties involved if needed. Residents interviewed stated that they are given their medications on time and staff give it to them properly. On 7/22/2022 LPA David Marrufo interviewed ten residents and three staff who stated they staff have never misplaced residents medication.

Based on facility records review, interviews with residents and staff on the information provided, it was unclear if staff misplaced resident’s medication., therefore the allegation was deemed UNSUBSTANTIATED.

Staff failed to keep facility free of pests - LPA Lund reviewed facility records, interviewed staff, and residents in care. Based on reviewed facility records, interviews with staff, and residents in care. LPA Lund reviewed Clark Pest Control report dated 5/6/2022 states the facility is clear of rodents. LPA Lund reviewed pest control reports from 4/29/2024 through 10/24/2024 states the facility is clear of pests and rodents. Staff interviewed stated that have not seen any rodents are pests at the facility. Residents interviewed stated that have not seen any rodents are pests at the facility. On 7/22/2022 LPA David Marrufo interviewed ten residents and three staff who stated the facility is free of pests.

Based on facility records review, interviews with residents and staff on the information provided, it was unclear if staff failed to keep facility free of pests, therefore the allegation was deemed UNSUBSTANTIATED.

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20220714111842

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: LAUREL HAVEN	FACILITY NUMBER: 435202423
	VISIT DATE: 10/26/2024

NARRATIVE

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Facility restrains residents in their bedrooms - LPA Lund interviewed staff, and residents in care. Based on interviews with staff, and residents in care. Staff interviewed stated that they have never told any residents to staff in their rooms unless it was under if they have had COVID-19 and we would try to tell residents in care to stay in their rooms. Residents interviewed stated that they have never been forced to stay in their rooms. On 7/22/2022 LPA David Marrufo interviewed ten residents and three staff who stated the facility has never forced residents to stay in their rooms.

Based on interviews with residents and staff on the information provided, it was unclear if facility restrains residents in their bedrooms, therefore the allegation was deemed UNSUBSTANTIATED.

As a result of this investigation, this Department finds the allegation to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted and report left.

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2024

LIC9099 (FAS) - (06/04)

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