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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202461
Report Date: 09/14/2022
Date Signed: 09/14/2022 04:50:35 PM

Document Has Been Signed on 09/14/2022 04:50 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:
09/14/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Eugene DeLeonTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Eugene DeLeon. The purpose of the visit was to investigate a report of an incident of staff abusing a resident.

During visit, LPA Marrufo interviewed residents R1-R5 and staff S1-S3. LPA Marrufo obtained copies of the following resident records: Emergency Contact Form, Physician's Report, Appraisal/Needs and Services Plan, and Medication Administration Record.

No deficiencies were cited at this time as per California Code of Regulations Title 22.

This report was reviewed with Eugene DeLeon and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2022
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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