435202423-1-17-2024-26-AS-KHOS-D45HZ2-20240408063738

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202423
Report Date: 01/17/2024
Date Signed: 01/17/2024 11:26:35 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/28/2023 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20231228114456

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:	01/17/2024
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Alex Ignacio		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Facility unlawfully evicted a resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Alex Ignacio, staff.

On 12/28/2023, the Department received a complaint with the above allegation. On 01/03/2024, LPA Marrufo conducted an initial complaint investigation visit.

LPA Marrufo obtained a screenshot of the text message that Licensee sent to resident R1's Case Worker on 12/28/2023. LPA Marrufo verified that the telephone number from where the text message was sent to R1's case worker is the same telephone number LPA Marrufo has used to contact the Licensee.

See LIC9099-C for more information. Page 1 of 2.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024

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-20231228114456

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 HAVEN	FACILITY NUMBER: 435202423
	VISIT DATE: 01/17/2024

NARRATIVE

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The text message states, "...When I asked you for the 150 approval last September - you said it was approved. Just the email for the 55 patch in which to don't take. So pls find another place for [R1] as this is a 30 day notice. Ty"

The text message did not include any of the five reasons for an eviction that a Licensee may provided as stated in Title 22 Regulation 87224 Eviction Procedures (a)(1-5).

During interview, R1's Case Worker stated to have not received any other form of eviction notice. R1 stated during interview to have not received any verbal or written notice of eviction.

A deficiency was cited as per California Code of Regulations Title 22. See LIC809-D for more information.

This report was reviewed with Alex Ignacio and a copy of the report was provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20231228114456

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 HAVEN	FACILITY NUMBER: 435202423
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/17/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/24/2024 Section Cited CCR 87224(a)	1 2 3 4 5 6 7	87224 Eviction Procedures (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5). This requirement	1 2 3 4 5 6 7	Licensee agrees to submit a statement of understanding by POC date to CCL stating that the licensee has reviewed and understood CCL Regulation 87224 Eviction Procedures. Licensee also agrees to rescind or correct any current evictions that do not
	8 9 10 11 12 13 14	was not met as evidenced by: Licensee sent a text message to R1's case worker stating that R1 was being evicted for not paying the full patch amount. The text message did not include any of the legal reasons for eviction as stated in 87224(a)(1-5), which poses a potential safety risk to residents in care.	8 9 10 11 12 13 14	comply with CCL Regulation 87224 Eviction Procedures by POC date. Licensee shall either submit copies of rescinded or corrected eviction notices or issue a statement that there are no current non-compliant evictions by POC date.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 3