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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415600729
Report Date: 03/25/2026
Date Signed: 03/25/2026 02:17:14 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/04/2026 and conducted by Evaluator Jaime Vado
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20260204105434
FACILITY NAME:BEL AMOR IIIFACILITY NUMBER:
415600729
ADMINISTRATOR:DEANDA, OLIVIA & MANNYFACILITY TYPE:
740
ADDRESS:169 SAN FELIPE AVENUETELEPHONE:
(650) 871-7931
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY:6CENSUS: 6DATE:
03/25/2026
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator - Olivia Deanda TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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- Staff are not documenting medication properly

INVESTIGATION FINDINGS:
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On 03/25/2026, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint inspection visit to deliver findings regarding the allegations received. LPA met with Olivia Deanda and explained the purpose of today's visit.

During the investation, LPA interviewed staff and reviewed pertinent documents. LPA reveiwed facility's centralized medication record and daily record for medications. Per review, LPA observed that the medications are logged correctly in the centralized medication record for prescribed medications, but for the daily record for medications, LPA did observe prefilling of medications being administered to a resident for a few days, which supports the information received as part of the complaint. It was indicated in the complaint supporting documents that medications were marked as from 1/13/26 to 1/20/26 before they were actually given and this record was observed by the complaining party on 1/14/26. LPA observed this record and confirmed observation and the reporting of this. Based on this observation, LPA confirmed that PRN medication is not accurately documented on the MAR for R1. This allegation is substantiated.

Based on LPA interviews and items received, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, are being cited on the attached LIC9099D. Report is reviewed with administrator. A copy of report is provided with appeal rights.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2026
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 14-AS-20260204105434
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: BEL AMOR III
FACILITY NUMBER: 415600729
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/02/2026
Section Cited
CCR
87506(a)
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87506(a) Resident Records. A separate, complete, and current record shall be maintained for each resident in the facility, readily available to facility staff and to licensing agency staff and shall contained specified information. This regulation has not be met as evidenced by:
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Facility shall ensure compliance with this regulation at all times by submitted a plan addressing the regualtion and correcting the records indicating this regualation is followed at all times.
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Based on medication administration record (MAR) observed, R1's medication was prefilled in sowing it was administered for at lease two weeks prior to when it was actually given. This poses a potential health and safety risk to resident in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/04/2026 and conducted by Evaluator Jaime Vado
COMPLAINT CONTROL NUMBER: 14-AS-20260204105434

FACILITY NAME:BEL AMOR IIIFACILITY NUMBER:
415600729
ADMINISTRATOR:DEANDA, OLIVIA & MANNYFACILITY TYPE:
740
ADDRESS:169 SAN FELIPE AVENUETELEPHONE:
(650) 871-7931
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY:6CENSUS: 6DATE:
03/25/2026
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator - Olivia Deanda TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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- Staff is not qualified
- Staff did not get timely medical care for resident
- Administrator is not at facility the required amount of time
INVESTIGATION FINDINGS:
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On 03/25/2026, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint inspection visit to deliver findings regarding the allegations received. LPA met with Olivia Deanda and explained the purpose of today's visit.

During the investigation, LPA interviewed staff and reviewed pertinent documents. Based off of interviews, the regular administrator was out of the country at the time of the complaint but a back up administrator was assigned and present. During complaint investigation the administrator was present to assist. Per staff training reviewed, staff have training on file and are conduct the annual training hours. Staff were able to assist and explain a situation with a resident due to a medical situation that always happens. Staff identified, notified the administrator, and told a visit nurse of the situation. Based on these observations and interviews, these allegations are unsubstantiated.

Based on these observations, the above allegations are UNSUBSTANTIATED.
Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated at this time. Report is reviewed wit the administrator and a copy is provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2026
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 3