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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430706162
Report Date: 01/08/2025
Date Signed: 01/08/2025 01:47:27 PM

Document Has Been Signed on 01/08/2025 01:47 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: 20DATE:
01/08/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Licensee/Administrator Amor Valin and Administrator Virgil ValinTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Simi Rai and Marcela Yanez conducted an unannounced case management visit to conclude the investigation initiated on 10/24/2024. LPAs met Licensee/Administrator Amor Valin and Administrator Virgil Valin and stated the purpose of today’s visit.

On 10/24/2024, the Department conducted a case management visit to follow up on an incident report received on 10/23/2024 regarding resident (R1) left the facility without staff knowledge and was reported missing by facility staff.

On 10/24/2024, 3 staff were interviewed. 3 Out of 3 staff stated on 10/23/2024 during lunch time, approximately noon, they observed R1 present in the facility. Staff S2 stated during snack time which was at approximately 3:00pm, staff observed R1 was not present at the facility. Staff waited for R1 to return to the facility until dinner time at approximately 5pm and realized resident was not back at the facility. The facility staff searched around 3-mile radius but were not able to locate R1. R1 was reported to local law enforcement as missing person. 3 Out of 3 staff stated R1 had wandering behaviors and staff ensured R1 did not leave the facility and did not leave R1 alone. Staff stated they were not able to communicate and assess the R1’s needs because R1 did not speak English and they did not speak R1’s language.

During today’s visit, LPAs interviewed ADM and LIC. R1 returned back to the facility on 10/24/2024 at 7pm. ADM stated all residents are supervised at the facility for the first month following their admission to the facility. ADM stated the day of 10/23/2024, R1 did not sign out of the log before leaving the facility. LIC stated R1 was displaying wandering behavior during the first couple of days of admission where R1 would leave the facility building and walk towards the gate located at the front of the facility. ADM stated R1 can understand English and speak English.

Continuation on LIC 9099-C, Page 1 of 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/08/2025
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
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: 01/08/2025
NARRATIVE
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Page 2 of 2.

During today's visit, LPAs interviewed R1. LPAs asked R1 questions and R1 would respond with one word answers such as "Yes" and "No". R1 was not able to answer basic questions as R1's name, date of birth or today's date. R1 is able to understand nonverbal cues such as pointing to the door when asked to close the door or pointing to the head when asked if R1's head hurts.

Based on review of Incident Report 10/23/2024, Administrator stated the residents who leave the facility would return for dinner. 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, R1 is monolingual and does not speak English. Based on review 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 from 3/30/2019-10/2/2024 and R1 was admitted to the facility on 10/3/2024.

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

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 9099-D.

A civil penalty is being assessed for the amount of $500 for the absence of supervision at the facility. Please see LIC421IM.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

This report was reviewed with Licensee/Administrator Amor Valin and Administrator Virgil Valin and a copy of the report was provided. Appeal Rights was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 01/08/2025 01:47 PM - It Cannot Be Edited


Created By: Simranjit Rai On 01/08/2025 at 12:19 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: AMOR RESIDENTIAL CARE HOME
FACILITY NUMBER: 430706162

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/09/2025
Section Cited
HSC
1562.6(a)

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1562.6(a)The administrator of an adult residential care facility that provides services for residents who have mental illness shall ensure that a written intake assessment is prepared by a licensed mental health professional prior to acceptance of the client...
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Licensee/Administrator stated to submit a written plan of action understanding regulation and will esnure residents have a written intake assessment prior to admission to the facility by POC due date. Licensee/Administrator agreed and understood.
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This requirement is not met as evidenced by: Based on record review of R1, R1 has a mental illness, and a written intake assessment was not prepared by a licensed mental health professional prior to acceptance of the client which poses/posed an immediate Health, Safety, or
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(con't) Personal Rights risk to persons in care.
Type A
01/09/2025
Section Cited
CCR87468.2(a)(4)

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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)(4) To care, supervision, and services that meet their individual needs ... by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by:
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Licensee/Administrator stated to submit a written plan of action understanding regulation and will train staff on providing care and supervision by POC due date. Licensee/Administrator agreed and understood.
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Based on interviews conducted, resident R1 left the facility without the knowledge of the staff on 10/23/2024, staff did not provide R1 with care, supervision, and communication to meet his/her needs which poses/posed an immediate Health, Safety or Personal Rights risk to persons 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.
SUPERVISOR'S NAME:Romeo Manzano
LICENSING EVALUATOR NAME:Simranjit Rai
LICENSING EVALUATOR SIGNATURE:
DATE: 01/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 01/08/2025 01:47 PM - It Cannot Be Edited


Created By: Simranjit Rai On 01/08/2025 at 12:23 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: AMOR RESIDENTIAL CARE HOME
FACILITY NUMBER: 430706162

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/09/2025
Section Cited
CCR
87468.1(a)(2)

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87468.1 Personal Rights: (a)(2) Each resident shall be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement was not met as evidenced by:
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Licensee/Administrator stated to submit a written plan of action understanding regulation and will train staff on providing care and supervision by POC due date. Licensee/Administrator agreed and understood.
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Based on interview and record review, on 10/23/2024 resident R1 left the facility without signing out on the logbook and staff were unaware of R1 leaving the facility for approximately 3 hours which poses/posed an immediate Health, Safety or Personal Rights risk to persons 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.
SUPERVISOR'S NAME:Romeo Manzano
LICENSING EVALUATOR NAME:Simranjit Rai
LICENSING EVALUATOR SIGNATURE:
DATE: 01/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2025


LIC809 (FAS) - (06/04)
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