435202425-7-22-2020-26-AS-GNWR-BRSRZN-20200723132811

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202425
Report Date: 07/19/2020
Date Signed: 07/22/2020 09:30:24 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
07/07/2020 and conducted by Evaluator Maria Kamara

COMPLAINT CONTROL NUMBER: 26-AS-20200707085854

FACILITY NAME:	LAUREL CREST MANOR		FACILITY NUMBER:	435202425
ADMINISTRATOR:	SAMONTE, SOL		FACILITY TYPE:	740
ADDRESS:	2468 NIGHTINGALE DRIVE		TELEPHONE:	(408) 265-2263
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95125
CAPACITY:	6	CENSUS: 4	DATE:	07/19/2020
		UNANNOUNCED	TIME BEGAN:	06:00 PM
MET WITH:	Merle Laurel-Administrator		TIME COMPLETED:	07:30 PM

ALLEGATION(S):

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Staff are not able to provide medical records for emergency personnel.

INVESTIGATION FINDINGS:

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On 7/21/2020, Licensing Program Analyst (LPA) Maria Kamara conducted an unannounced subsequent complaint investigation via tele-conference call with the facility, spoke with Merle Laurel, Administrator and was informed of the purpose for the call, which was to deliver finding on the above allegation. LPA Maria informed Administrator Merle that due to the current COVID-19 "shelter in place" the Department is currently conducting tele-conference call in the place of an on-site complaint investigation.

On 7/17/2020, at 11:00AM, during the complaint investigation visit there were four residents and two staffs present at the home. LPA Maria did a wellness check on the residents via Facetime video call.

On 7/17/2020, at 11:15AM, LPA Maria interviewed two residents. (R2), one out of the two residents interviewed stated that she's doing fine and had no problems at the facility. (R2) stated that she has never had any problems with her medical records when she needs medical attention. Resident (R3) was unable to respond or answer to LPA's investigation questions.

See Pg.2 of LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: George Nwafor	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Maria Kamara	TELEPHONE: (650) 388-2295
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2020

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-20200707085854

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: LAUREL CREST MANOR	FACILITY NUMBER: 435202425
	VISIT DATE: 07/19/2020

NARRATIVE

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Pg.2

Resident (R1) was not available for interview as (R1) was not present at the facility. R1 is currently admitted to the hospital for medical reasons. (R2) denied the allegation “Staff are not able to provide medical records for emergency personnel".

On 7/17/2020, at 11:28AM, three staffs, (S1-S3) were interviewed and stated that staff follows facility protocols on medical emergencies with residents. Staffs (S1-S3) stated that
(R1) is not able to manages her physical needs and her (ADL's) activity of daily living. Staff (S1-S3) stated resident (R1) uses a walker and walks very slow. They stated that It is difficult to understand how (R1) talks due to her medical diagnosis. Staff (S1-S3) stated that on 6/25/2020 staff had observed changes on (R1's) condition and 911 was called and resident was taken to Valley Medical Center hospital for medical attention but was discharged and returned the same day to the facility with no new diagnosis.

Staff (S1-S3) stated that on 7/3/2020 at about 5:30PM due to staffs continuous observation on (R1's) condition staff called the (EMS) Emergency Medical Services Silicon Valley Ambulance and arrived shortly. Staff (S1 & S2) who were present at the facility when (R1) was been picked up stated that the following information for (R1) was provided, VIAL of L.I.F.E, all current medications and the LIC602 Physician's Report which is the usual routine documents provided for any medical personnel including 911 emergency responders. Lead Staff (S1) stated that she was able to provide the EMS dispatcher a brief description of resident (R1's) medical condition and informed EMS dispatcher that resident (R1) was taken to the hospital via 911 on 6/25/2020 for the same medical condition. Staffs indicated that they gave all documents that the facility is required to provide for medical personal for R1. Staffs (S1-S3) denied the allegation "Staff are not able to provide medical records for emergency personnel”.

See continuation Pg.3 of LIC9099C

SUPERVISOR'S NAME: George Nwafor	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Maria Kamara	TELEPHONE: (650) 388-2295
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20200707085854

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: LAUREL CREST MANOR	FACILITY NUMBER: 435202425
	VISIT DATE: 07/19/2020

NARRATIVE

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Pg.3

On 7/17/2020 at 1:30PM, residents (R1, R2, R3) and two staff’s records were reviewed. Copies of documents pertaining to the complaint were obtained.

Based on available information gathered, LPA's inspection, observations, interviews with staffs, residents, records review, and review of supporting documents obtained during the cause of the investigation, on the above allegation, the preponderance of evidence standard has been met. The allegation "Staff are not able to provide medical records for emergency personnel” is found to be UNSUBSTANTIATED meaning although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is dismissed. No deficiencies were cited as a result of this complaint investigation. Exit interview is conducted with Administrator Merle Laurel.

LPA Maria informed Administrator Merle Laurel that a signed PDF copy of the LIC9099 by LPA Maria will be emailed to the facility for signature and returned to LPA Maria and also submit the original signed document to CCL office via mail. Document was emailed to Merle Laurel (merle.laurel@gmail.com).

SUPERVISOR'S NAME: George Nwafor	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Maria Kamara	TELEPHONE: (650) 388-2295
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2020

LIC9099 (FAS) - (06/04)

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