435202425-7-23-2024-26-AS-RMAO-D8943H-20240817184442

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202425
Report Date: 07/23/2024
Date Signed: 07/23/2024 12:42:13 PM

Unsubstantiated

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
08/10/2022 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20220810152636

FACILITY NAME:	LAUREL CREST MANOR		FACILITY NUMBER:	435202425
ADMINISTRATOR:	MERLE LAUREL		FACILITY TYPE:	740
ADDRESS:	2468 NIGHTINGALE DRIVE		TELEPHONE:	(408) 265-2263
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95125
CAPACITY:	6	CENSUS: 6	DATE:	07/23/2024
		UNANNOUNCED	TIME BEGAN:	12:20 PM
MET WITH:	Staff S3, Josephine Eaguro		TIME COMPLETED:	12:50 PM

ALLEGATION(S):

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Staff hit resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegations. LPA met with S3 Josephine Eaguro. Staff S3 contacted facility ADM, who stated S3 could sign on her behalf.

On August 10, 2022, the department received a complaint alleging staff hit a resident. It has been alleged that 2 years ago (2020), while resident R1 was being bathed, staff S1 subsequently hit R1.

On August 17, 2022, LPA Dolores interviewed residents R2-R4. 3 Out of 3 residents interview stated the staff are nice and treat them good. 3 Out of 3 residents interviewed stated the staff never hurt them and they did not observe staff hurt other residents.

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024

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-20220810152636

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 CREST MANOR	FACILITY NUMBER: 435202425
	VISIT DATE: 07/23/2024

NARRATIVE

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LPA interviewed S1 & S2. S1 stated they did not observe bruising on R1 or hear complaints of pain. S1 stated R1 never complained to staff of any incidents of staff hurting R1. S2 stated he/she never hurt R1. S2 stated the staff would not hit anyone.

LPA interviewed ADM. ADM stated the staff would never hit a resident. ADM stated R1 never complained of pain or that someone had hit them.

Based on a review of R1’s Physician’s Report, dated January 14, 2021, R1 has a neurocognitive disorder.

The Department made serval attempts to contact S1 but was unable to get in contact with him/her. S1 no longer works at the facility.

The Department was unable to get to interview Resident R1. Resident R1 no longer lives at the facility.

Witness did not provide additional information regarding the allegation above.

Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.

No deficiencies cited, an exit interview conducted with staff S3 and a copy of the report was provided.

END OF REPORT

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SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024

LIC9099 (FAS) - (06/04)

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