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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202425
Report Date: 06/09/2022
Date Signed: 06/09/2022 10:56:26 AM


Document Has Been Signed on 06/09/2022 10:56 AM - 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: 5DATE:
06/09/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Merle LaurelTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) David Marrufo, LPA Mandeep Kaur, Licensing Program Manager (LPM) Romeo Manzano, and Program Clinical Consultant (PCC) Nurse Helen Shi conducted a tele-visit via Zoom to provide technical assistance to prevent and mitigate the spread of COVID-19 at the facility and met with Administrator Merle Laurel.

Anna Zarragal reports that there are currently 0 COVID-19 positive residents and 0 COVID-19 positive staff.

During today's tele-visit, PCC Nurse Helen Shi made the following recommendations to the facility:

1. Place sign at entrance advising visitors to wear a mask.
2. Have signs ready to use to identify isolation rooms and to instruct staff on donning and doffing of PPEs.
3. Have staff use paper towels instead of cloth towels, and remind them to not have cloth towels exposed.

No deficiencies were cited as per California Code of Regulations, Title 22.

This report was reviewed with Administrator Merle Laurel. A copy of the report will be sent to them for it be signed and returned to CCL.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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