435202425-9-14-2024-26-AS-RMAO-D9BTT4-20240921150008

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202425
Report Date: 09/14/2024
Date Signed: 09/14/2024 12:19:01 PM

Unfounded

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
07/26/2022 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20220726140626

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: 5	DATE:	09/14/2024
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Luzviminda "Minda" Obillo		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff neglected to provide care for resident injury
Facility did not report resident injury to Licensing
Facility did not notify resident's family or responsible party of injury

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegations. LPA met with staff Lead Luzviminda "Minda" Obillo.

On July 26, 2022, the department received a complaint alleging facility staff neglected to provide care for resident injury.

On August 3, 2022, LPA Dolores interviewed staff S1 and S2. S1 stated he/she saw a bruise on R1’s chest and swelling on the clavicle on July 18, 2022. S1 stated R1 did not express pain and thought it was only R1’s Arthritis. S1 stated he/she massaged R1's chest and clavicle area and put Salonpas on the areas of concern. S1 stated on July 21, 2022, S1 called On Lok (R1's medical provider) to check on R1 because R1's face expressed a little pain. S1 stated staff can tell when R1 has pain thru his/her facial expressions. S1 stated on July 22, 2022, around 10:00am, On Lok picked up R1.
Page 1 Out of 3.

Unfounded

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: 09/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2024

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-20220726140626

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: 09/14/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Staff S2 stated he/she noticed the swelling on July 18, 2022. S2 talked to S1 about the swelling and S1 was putting Salonpas on the affected area. S2 stated when R1 felt better he/she said "ok, ok”. S2 stated he/she thought it was R1’s arthritis and R1 never expressed pain. S2 stated the facility staff can tell when R1 is in pain through her facial expressions. Staff S1 and S2 stated they did not observe R1 fall or sustain an injury.

On August 11, 2022, LPA interviewed ADM. ADM was notified by staff on July 21, 2022 that R1 had slight swelling but was able to still move around. ADM stated she observed the swelling and informed staff S1 to call On Lok to schedule an appointment with R1’s doctor to be evaluated. ADM stated R1 was still able to hold onto his/her walker, go to the bathroom, move his/her arms and legs. ADM stated when she asked R1 how he/she was doing R1 verbalized a little bit that it was hurting but R1 was not grimacing.

Based on a review of R1’s Physicians Report, dated July 21, 2022, R1 is able to follow instructions and is able to communicate needs, via cueing.

Based on a review of R1’s Needs and Services Plan, dated January 1, 2022, resident R1 will respond if asked and speaks basic English.

Based on a review of R1’s discharge summary, dated July 26, 2022, CT scans were done on R1 and R1 had no signs of fracture. The discharge summary also stated the bruises on R1’s chest is more likely pigmentation. The summary also states R1 has a neurocognitive disorder and is nonverbal mostly.

The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

No deficiencies cited, an exit interview conducted with Lead Luzviminda "Minda" Obillo and a copy of the report was provided.

Page 2 Out of 3.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20220726140626

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: 09/14/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Facility did not report resident injury to Licensing/Facility did not notify resident's family or responsible party of injury

On July 26, 2022, the department received a complaint alleging Facility did not report resident’s injury to licensing. It has also been alleged, the facility did not notify the resident’s family or responsible party of injury.

Based on interview and record review, on July 18, 2022, resident R1 was observed with swelling.

On August 11, 2022, LPA Dolores interviewed ADM. ADM stated he/she called late Friday afternoon and left a voicemail for Community Care Licensing main line. ADM also states to have sent an incident report to Licensing.

On October 11, 2022, LPA Dolores interviewed R1’s Responsible Party. (R1RP) R1RP stated he/she was informed by facility staff the day R1 was sent out (July 22, 2022). R1RP stated he/she was informed by the facility that they noticed some swelling on R1’s chest and they called On Lok.

Based on record review, the Department received an incident report dated July 22, 2022. The incident Report was sent by the ADM. The incident report states staff called on LOK Clinic to report R1 had slight swelling on R1’s Clavicle and bruise in the breast area, with no fall or injury noted. The Department received this incident report on July 25, 2022.

The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

No deficiencies cited, an exit interview conducted with Lead Luzviminda "Minda" Obillo and a copy of the report was provided.

Page 3 Out of 3.

END OF REPORT.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 3