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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202425
Report Date: 04/27/2022
Date Signed: 04/27/2022 12:01:11 PM


Document Has Been Signed on 04/27/2022 12:01 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 MANORFACILITY NUMBER:
435202425
ADMINISTRATOR:MERLE LAURELFACILITY TYPE:
740
ADDRESS:2468 NIGHTINGALE DRIVETELEPHONE:
(408) 265-2263
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY:6CENSUS: 6DATE:
04/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:34 AM
MET WITH:Merle LaurelTIME COMPLETED:
12:05 PM
NARRATIVE
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection. LPA met with facility staff member Minda Obillo (S1). LPA contacted Administrator Merle Laurel (Admin) via phone, who indicated that they were unable to attend the inspection. Admin gave (S1) permission to conduct the inspection in their stead.

LPA toured the facility, including kitchen, living room, garage, 4 resident bedrooms, one staff bedroom, three bathrooms, and backyard. Staff members were not observed to be wearing masks. S1 confirmed that all staff and residents have been vaccinated.

No prohibited items noted in resident rooms. All emergency exits noted to be clear of obstruction. All rooms in facility noted to be clean and well maintained. Hand sanitizers and soap were observed to be available. Bathrooms observed to not be stocked with paper towels. At least 2 days' supply of perishable food and at least 1 week's supply of non-perishable food was observed on the premises. Fire extinguisher observed to be inspected in February 2022. Smoke alarms were tested and observed to be functioning properly. All cleaning supplies and chemicals noted to be in locked cabinets and closets.

Facility observed to have a designated entry point. Staff took LPA's temperature and screened for symptoms. Facility did not have 30 days supply of PPE. Social distancing signs observed to be posted in all public areas. Hand washing signs were observed in facility bathrooms. Water temperature observed to be 138 *F. 18 degrees over the limit.

Deficiency cited during today's visit. See 809-D. Advisory notes issued. This report was reviewed with Administrator Merle Laurel and signed by staff member Minda Obillo. A copy of the signed report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5


Document Has Been Signed on 04/27/2022 12:01 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
80088(e)(1) Furniture, Fixtures, Equipment, and Supplies - (e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, as the facility water temperature was measured at 138*F. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2022
Plan of Correction
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Facility to reduce water temperature to acceptable levels and provide proof of correction by POC due date, as well as a tempertature log for 1 week.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2022
LIC809 (FAS) - (06/04)
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