435202425-9-14-2024-26-AS-RMAO-D9BTXE-20240921150702

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202425
Report Date: 09/14/2024
Date Signed: 09/14/2024 12:23:40 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
03/09/2023 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20230309140050

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 staff Luzviminda "Minda" Obillo.		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Resident is being financially abused.

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 staff Luzviminda "Minda" Obillo.

On March 9, 2023, the Department received a complaint alleging Resident is being financially abused. It has been alleged a staff member obtained two blank checks from R1 and one of those blank checks have not been cashed.

On March 20, 2023, the Department received an email communication from R1’s Family member (FM). FM stated he/she discussed this situation with R1. FM stated R1 was concerned that he/she owed back rent and felt relief the rent would be paid by signing the checks. FM stated the two checks were paid to facility with the correct amount for the month of February and March 2023.

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 4

Control Number 26-AS-20230309140050

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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A review of R1’s physicians report, dated June 1, 2022, states R1 can handle his/her own cash resources.

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

Page 2 Out of 2.

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: 2 of 4

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
03/09/2023 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20230309140050

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 staff Luzviminda "Minda" Obillo.		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Resident sustained a broken bone while in care.

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 staff Luzviminda "Minda" Obillo.

On March 9, 2023, the Department received a complaint alleging Resident R1 sustained a broken bone while in care.

On March 20, 2023, LPA Marrufo interviewed Witness 1 (W1). W1 stated R1 would walk in the front yard and sometime walk a couple blocks to the local store. W1 stated R1 was trying to walk out front in the driveway of the house. W1 stated R1 is very independent minded and refused help. W1 stated R1’s fall was at the driveway of the facility.

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)

Page: 3 of 4

Control Number 26-AS-20230309140050

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 5, 2024, LPA Monter interviewed Staff S1 and ADM. Staff S1 stated she does not remember working that day and does not remember the details as she cannot recall. ADM stated R1 always wants to do things him/herself. ADM stated resident R1 was aware that he/she could not leave the facility unassisted but insists on going by herself to the store or doctors’ appointments. ADM stated she has discussed this with the family and had R1 sign in and out in the book.

On September 14, 2024, LPA interviewed staff S2. S2 stated R1 had signed out to go for a walk to 7/11. S2 stated resident R1 insisted on walking by him/herself. S2 stated R1 had returned to the facility and told the staff that he/she had fallen.

Based on a review of R1’s Physician Report dated, June 1, 2022. Resident R1 does not have a neurocognitive disorder. Resident R1 is ambulatory but cannot leave the facility unassisted.

A review of R1’s Needs and Services Plan (ANS), dated January 20, 2023, states R1 uses a walker for long distances and walks around the house without an assistive device. The ANS also states R1 is more stable in his/her mobility after physical therapy completed. The ANS states R1 walks very well alone and refuses to be assisted, stating he/she wants to do things for him/herself.

Based on a review of facility Unusual Incident Report, dated January 24, 2023, states on January 23, 2023, at 5:30pm, resident R1 came back home after a walk to the 7/11 and stated he/she fell.

Based on a google maps search, the facility is 0.2 miles away from the 7/11. With an estimated walking time of 5 minutes.

The Department was unable to interview resident R1 during the course of this investigation. Resident R1 no longer lives at the facility.

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 of neglect/lack of supervision did or did not occur.
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: 4 of 4