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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430706162
Report Date: 04/09/2025
Date Signed: 05/30/2025 09:51:46 AM

Document Has Been Signed on 05/30/2025 09:51 AM - 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:
04/09/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:Amor Valin - AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced case management visit for the incident that was reported on 10/23/2024 and investigation was initiated on 10/24/2024. LPA met Licensee/Administrator Amor Valin and Virgil Valin and stated the purpose of the visit is to amend the report that was delivered on 1/8/2025 based on additional information.

On 10/24/2024, the Department conducted a case management visit to for the incident report received on 10/23/2024 regarding resident (R1) who left the facility without staff's knowledge. R1 was found the next day by law enforcement (10/24/2024).

On 10/24/2024, the Department interviewed 3 staff (S1, S2 & S3). 3 Out of 3 staff stated on 10/23/2024 during lunch time, approximately noon, they observed R1 was present at the facility. Staff S2 stated during snack time which was served at 3:00pm observed that R1 was not present at the facility. Staff reported to ADM that R1 was missing and law enforcement was called as soon as R1 was confirmed to be missing from the facility. The facility staff searched within the 3 mile radius but was not able to locate R1.

Based on staff interview, 3 Out of 3 staff, stated that R1 recently moved to the facility and will always go to the gate, wanting to leave. 3 Out of 3 staff stated that ADM have instructed all staff to watch over R1 because R1 is new and is not familiar with his/her current surroundings. 3 Out of 3 staff stated that there will always be a staff by the gate to watch over the residents who are coming and going through the gate.

Continuation on LIC 9099-C, Page 1 of 3.
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/09/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/09/2025
NARRATIVE
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Based on observation and interview with staff, the gate is equipped with a bell alarm system alerting staff when a person/individual opens the gate.

3 Out of 3 staff stated R1 appears to have a wandering behavior and does not communicate well in English. Staff stated that R1 likes to speak with his/her roommate who spoke the same language as himself/herself. Staff stated based on R1s assessment, R1 can leave the facility unassisted. Staff were instructed by ADM because of the fact that R1 was new and still adjusting to his/her new environment should be supervised and assisted until R1 adjust to the new environment. 3 Out of 3 staff stated R1 was recently admitted and been in the facility for less than a month.

3 Out of 3 staff stated that during the time of the incident 10/23/2024, around 2:00 p.m. ADM called for a staff meeting and most staff were present except for one. 2 out of 3 staff stated the door was closed because it was cold. 1 out of 3 stated that the door was open. 3 Out of 3 stated they did not see R1 leave because they were all facing towards the office. 3 Out of 3 staff stated, one staff was left behind to look after all the resident's coming and going while the meeting is in progress. 3 Out of 3 staff stated the meeting lasted for less than an 30 minutes.

3 Out of 3 staff stated they were alerted that a resident opened the gate because of the loud alarm when the gate opened, but did not see R1 leave. 3 Out of 3 stated it was another resident that they saw. 3 out of 3 staff stated that the window in the office is huge so they can see residents passing when the gate alarms.

R1 was found on 10/24/2024 by law enforcement and R1 was brought to the hospital for assessment. R1 returned back to the facility at approximately 7:00 p.m.

On 4/9/2025, the Department interviewed ADM who stated that new residents are supervised at the facility for the first month after admission. ADM stated the day of 10/23/2024, R1 did not sign out of the log before leaving the facility and was not seen on the surveillance camera. LIC/ADM stated R1 was displaying wandering behavior during the first couple of days of admission. R1 would leave the facility building and walk towards the main gate, however, staff is able to stop R1 prior to the incident from leaving because staff was always present by the front gate. ADM stated R1 can understand English and speak English.

Continuation on LIC 9099-C, Page 2 of 3
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/09/2025
NARRATIVE
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On 4/9/2025, LPA Partoza, attempted to interview R1 by asking questions. R1 would respond with one word answers which are "yes" or "no" . R1 was not able to state his/her name, date of birth or today's date but will communicate with ADM and facility staff.

Based on review of R1’s Physician’s Report dated 7/25/2024, R1 is able to leave facility unassisted but does not specify if R1 is confused/disoriented or has wandering behavior. Based on review of R1’s Appraisal/Needs and Services Plan 9/25/2024, states R1 is monolingual and does not speak English. Based on review of Visitor Sign In/Sign Out log, R1 did not sign out the day of 10/23/2024. Based on information provided by R1’s conservators (CO), the incident on 10/23/2024 was the first time out in the community and R1 was unfamiliar with the area and is very confused. CO stated R1 has been in a locked facility for 5 years (3/30/2019-10/2/2024) R1 was admitted to the facility on 10/3/2024.

Based on interviews and observation/inspection of the facility, the preponderance of evidence has been met therefore the above allegations is found to be SUBSTANTIATED.

Deficiencies were cited from California Code of Regulations, Title 22 on 1/8/2025 visit, see LIC 9099-D. However the case does not meet the criteria of absence of supervision, there for no civil penalty is warranted.

The Plan of Correction (POC) have been submitted to Community Care Licensing (CCL).

An exit interview was conducted with LIC/ADMs Virgil Valin and Amor Valin and a copy of the report was provided.

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End of Report
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025
LIC809 (FAS) - (06/04)
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