430706162-12-14-2022-26-AS-KHOS-CMKPXM-20221229104233

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 430706162
Report Date: 12/14/2022
Date Signed: 12/14/2022 02:31:38 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
09/29/2020 and conducted by Evaluator Christine Dolores

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20200929121955

FACILITY NAME:	AMOR RESIDENTIAL CARE HOME		FACILITY NUMBER:	430706162
ADMINISTRATOR:	VALIN, AMOR & VIRGIL		FACILITY TYPE:	740
ADDRESS:	32 NORTH 21ST STREET		TELEPHONE:	(408) 971-4244
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95116
CAPACITY:	24	CENSUS: 23	DATE:	12/14/2022
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Lourdes Basconcillo		TIME COMPLETED:	03:35 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Illegal eviction

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the findings to the above allegation. LPA met with caregiver, Lourdes Basconcillo. Administrators, Amor Valin and Virgil Valin was unable to meet LPA at the facility and designated Lourdes to sign off the report.

On 10/06/2020 S1 was interviewed. S1 stated R1 was showing behaviors of wanting to move out of the facility and staff tried to encourage R1 to stay. R1’s case manager and family were made aware. S1 also stated R1 was sent to the hospital to be evaluated for chest pains. The hospital called S1 to pick up R1, but S1 told the hospital that he could not take R1 back because R1 was refusing medication and does not want to be at the facility. S1 stated R1 was given a 30-day eviction notice, and R1’s case manager was looking for placement for R1. S1 denied illegally evicting R1.
See LIC9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022

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 2

Control Number 26-AS-20200929121955

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: AMOR RESIDENTIAL CARE HOME	FACILITY NUMBER: 430706162
	VISIT DATE: 12/14/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Eviction noticed was reviewed. The facility issued two eviction notices to R1. One eviction notice was issued on 06/06/2014 and the second eviction noticed was issued on 06/06/2020.

Email communication between the administrator and behavioral health agency showed the administrator was in contact regarding R1’s behavior and placement.

This Department has investigated the above allegation, and based on interviews and records review, the Department has determined that the allegation was Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

No deficiencies were cited per California Code of Regulations, Title 22.

This report was reviewed with Administrator, Amor Valin over the telephone and with caregiver, Lourdes Basconcillo and a copy of this report provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2