435202423-10-26-2024-26-AS-KHOS-DBCP3D-20241125095721

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202423
Report Date: 10/26/2024
Date Signed: 10/26/2024 05:11:30 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
10/04/2022 and conducted by Evaluator Jason Lund

COMPLAINT CONTROL NUMBER: 26-AS-20221004141551

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:	04:00 PM
MET WITH:	Administrator Merle Laurel		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Staff does not treat resident with dignity and respect
Administrator threatened resident
Staff did not let resident use the facility's telephone

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
Staff does not treat resident with dignity and respect - LPA Lund reviewed facility records, interviewed staff, and residents in care. Based on facility records review, interviews with staff, and residents in care. Staff have been trained on how to recognize & report elder abuse & understanding mental illness with residents with schizophrenia. Staff interviewed stated that they would report immediately to management if they were to see any staff yell at residents in care. Residents interviewed stated that they have not been yelled at by staff. On 10/10/2022 LPA David Marrufo interviewed six residents and three staff who stated they have never seen staff disrespect any residents in care.

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)

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Control Number 26-AS-20221004141551

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 staff does not treat resident with dignity and respect, therefore the allegation was deemed UNSUBSTANTIATED.

Administrator threatened resident - LPA Lund interviewed staff, and residents in care. Based on interviews with staff, and residents in care. Staff interviewed stated that they would notify management or call 1-844-LET-US-NO if they where to see the Administrator threatened a resident. Residents interviewed stated that they have never seen Administrator threatened any residents in care. On 10/10/2022 LPA David Marrufo interviewed six residents and three staff who stated they have never seen a administrator threaten an resident.

Based on interviews with residents and staff on the information provided, it was unclear if administrator threatened resident, therefore the allegation was deemed UNSUBSTANTIATED.

Staff did not let resident use the facility's telephone - LPA Lund interviewed staff, and residents in care. Based on interviews with staff and residents. Staff interviewed that resident have always been able to use the phone. Residents interviewed stated that they have been able to use the phone. On 10/10/2022 LPA David Marrufo interviewed six residents and three staff who stated they have been able to use the phone.

Based on interviews with residents and staff on the information provided, it was unclear if staff did not let resident use the facility's telephone, 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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