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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202461
Report Date: 08/27/2024
Date Signed: 08/27/2024 01:45:35 PM


Document Has Been Signed on 08/27/2024 01:45 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 LODGEFACILITY NUMBER:
435202461
ADMINISTRATOR:MERLE M. LAURELFACILITY TYPE:
740
ADDRESS:2247 SERRA AVE.TELEPHONE:
(408) 260-6880
CITY:SANTA CLARASTATE: CAZIP CODE:
95050
CAPACITY:6CENSUS: 5DATE:
08/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Staff, Lourdes De Leon TIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit. LPA Rai met with Staff, Lourdes De Leon and stated the purpose of today's visit. LPA Rai spoke with Administrator, Merle Laurel and stated the purpose of today's visit. Administrator gave verbal authorization for Staff to review and sign today's report. LPA Rai observed 2 staff and 5 residents at the facility.

During visit, LPA Rai toured the inside and outside of the facility. When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. Sharps and medications were locked in secured areas. LPA observed additional food supply areas and secured areas for cleaning supplies and laundry detergents.

LPA Rai toured the resident bedrooms. 5 Out of 5 resident bedrooms had available bedding, drawers, and functioning lights. The facility bathroom had available soap, paper towels, and trash cans with lids. The water temperature in the bathroom sinks ranged from 111.2 - 111.4 degrees F. The water temperature in the kitchen sink was 109.4 degrees F.

Fire extinguisher was observed and inspected on 01/22/2024. Facility smoke detectors and carbon monoxide detectors were in working condition. The last disaster drills were conducted on 07/01/2024 and 08/01/2024.

LPA Rai reviewed facility records for 2 staff and 2 residents. LPA Rai reviewed resident medications and central stored medication records.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Staff, Lourdes De Leon and a copy of the report was provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2024
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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