435202425-9-14-2024-26-AS-RMAO-D9BTP8-20240921145355

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202425
Report Date: 09/14/2024
Date Signed: 09/14/2024 12:21:07 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
08/29/2022 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20220829154416

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:	Lead Luzviminda "Minda" Obillo		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff did not immediately provide required information to paramedics causing delay in medical care to 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 Lead Luzviminda "Minda" Obillo.

On August 29, 2022, the department received a complaint alleging Staff did not immediately provide required information to paramedics causing delay in medical care to resident R1.

On September 8, 2022, LPA Christine Dolores interviewed S1. S1 stated called emergency services for resident (R1). S1 was helping R1 while on the phone with 911 and did not have time to make copies of the other information. S1 stated the paramedics requested for R1’s medical history and information, which S1 did not have a copy of the records readily available to medical personnel. S1 states this took maybe an additional 5 more minutes.

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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: 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)

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Control Number 26-AS-20220829154416

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

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On September 8, 2022, LPA Christine Dolores interviewed ADM. ADM stated the necessary paperwork was the 602 (physicians report) with the client's medical information. ADM states they normally don't give the paramedics the 602 and they only hand over the Vial of L.I.F.E form. Staff had given the Vial of L.I.F.E form to the paramedic but because the paramedic requested the 602, which then her staff had to go back to make copies.

On September 5, 2024, LPA interviewed resident R1. Resident R1 stated he/she does not remember what had occurred on August 28, 2022 and does not remember interacting with the paramedics.

On September 14, 2024, LPA interviewed Staff S2. Staff S2 stated he/she has trouble remembering the details of the event but stated they provided the paramedics with the documents they requested. S2 stated it took about 2 minutes to provide copies of R1's physician report and medication list.

LPA interviewed Witness W1. W1 stated August 28, 2022, staff on site were unable to provide any information regarding resident R1. W1 stated it took facility staff 10-15 minutes to provide the information regarding R1.

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 Lead Luzviminda "Minda" Obillo and a copy of the report was provided.

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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)

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