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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430706162
Report Date: 10/24/2024
Date Signed: 10/24/2024 01:12:23 PM

Document Has Been Signed on 10/24/2024 01:12 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:AMOR RESIDENTIAL CARE HOMEFACILITY NUMBER:
430706162
ADMINISTRATOR/
DIRECTOR:
VALIN, AMOR & VIRGILFACILITY TYPE:
740
ADDRESS:32 NORTH 21ST STREETTELEPHONE:
(408) 971-4244
CITY:SAN JOSESTATE: CAZIP CODE:
95116
CAPACITY: 24CENSUS: 18DATE:
10/24/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Lourdes Basconcillo - Lead Staff/House ManagerTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Maria (Mita)Partoza, conducted an unannounced case management inspection for the incident report that was received by the Department on 10/23/2024 regarding a resident who eloped and was reported missing. LPA was met by Lourdes Basconcillo who stated she's the lead staff/house manager (LS/HM) for the facility. The licensee/administrator Virgil Valin and Amor Valin was not present and stated that they were flying out to attend a seminar.

At 10:40 a.m. LPA toured the facility with LS/HM inside and outside and observed that walkways and pathways on the side and the front area are free from obstruction. LPA interviewed 3 staff (S1, S2, S3). 3 out of 3 staff stated that resident (R1) was very quiet and does not talk and likes to sit at the courtyard with other residents. R1 has a roommate (R2) who speaks the same language as R1. R2 stated that R1 does not say much and is quiet. 3 Out of 3 staff stated R1 was last seen by them in the morning and at lunch time.
S2 stated he/she did not notice R1 during snack time at 3:00 p.m. LPA requested documents from LS/HM.

Due to insufficient information this case management will remain open until further investigation.

No deficiencies were cited during today's visit. An exit interview was conducted with Lead Staff/House Manager Lourdes Basconcillo. A copy of the report was provided.

end of report
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2024
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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