445201621-4-4-2024-26-AS-KHOS-D4CJRT-20240415071715

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445201621
Report Date: 04/04/2024
Date Signed: 04/04/2024 04:39:19 PM

Substantiated

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
03/27/2023 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20230327090832

FACILITY NAME:	DE UN AMOR		FACILITY NUMBER:	445201621
ADMINISTRATOR:	FLETES, MARICELA		FACILITY TYPE:	740
ADDRESS:	460 EUREKA CANYON ROAD		TELEPHONE:	(831) 728-0303
CITY:	CORRALITOS	STATE: CA	ZIP CODE:	95076
CAPACITY:	25	CENSUS: 19	DATE:	04/04/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Saaj Kaiyom		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

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Staff are mismanaging resident's medication.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and wet with Administrator Saaj Kaiyom.

On 03/27/2023, the Department received a complaint with the above allegations. LPA Marrufo conducted an initial complaint investigation visit on 04/03/2023. Throughout the investigation, LPA Marrufo interviewed 8 residents, 6 staff, and Administrator Saaj Kaiyom. LPA Marrufo also reviewed the medications of 7 residents and obtained copies of staff training certificates for 5 staff, Activity Calendars for March and April 2023, and Bowel Movement Charts from January through March 2023 for 4 residents.

See LIC9099-C for more information. Page 1 of 2.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024

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 5

Control Number 26-AS-20230327090832

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: DE UN AMOR	FACILITY NUMBER: 445201621
	VISIT DATE: 04/04/2024

NARRATIVE

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Throughout the investigation, LPA Marrufo reviewed the medications of 7 residents. Of the 7 residents whose medications were reviewed, resident R1 had a medication that was to be taken once per day and based on the start date and quantity, should have had 70 pills remaining when the medications were reviewed. However, the medication only had 63 pills.

Resident R2 had a medication that, based on the start date, pill bottle quantity, and prescribed consumption rate of 1 pill per day, should have had 61 pills but had 64 pills.

Based on records review and observations there is preponderance of evidence to prove the alleged violation did occur. Therefore, the allegation is substantiated.

See 9099-D for deficiencies cited per the California Code of Regulations, Title 22.

This report was reviewed with Administrator Saaj Kaiyom and a copy of this report and appeal rights were provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 26-AS-20230327090832

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: DE UN AMOR	FACILITY NUMBER: 445201621
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/04/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/05/2024 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:	1 2 3 4 5 6 7	Licensee agrees to submit a Plan of Correction by POC date detailing how the licensee will conduct in-service training of staff on proper medication management and submit training rosters to CCL once in-service trainings are completed.
	8 9 10 11 12 13 14	(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: 2 out of 7 residents whose medications were reviewed had an incorrect amount of pills remaining in one of their medication bottles, which poses an immediate safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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
03/27/2023 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20230327090832

FACILITY NAME:	DE UN AMOR		FACILITY NUMBER:	445201621
ADMINISTRATOR:	FLETES, MARICELA		FACILITY TYPE:	740
ADDRESS:	460 EUREKA CANYON ROAD		TELEPHONE:	(831) 728-0303
CITY:	CORRALITOS	STATE: CA	ZIP CODE:	95076
CAPACITY:	25	CENSUS: 19	DATE:	04/04/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Saaj Kaiyom		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

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Staff leave residents soiled for an extended period of time.
Staff are not properly trained.
Staff do not provide residents with activities.

INVESTIGATION FINDINGS:

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8 out of 8 interviewed residents, 6 out of 6 interviewed staff and Administrator Saaj Kaiyom stated to have not observed staff leave residents soiled for an extended period of time.

LPA Marrufo did not observe any indication that staff were leaving residents soiled for an extended period of time during either the initial complaint investigation visit on 04/03/2023 or during today’s visit.

LPA Marrufo obtained copies of training records for 5 staff during visit on 04/03/2023. The staff training topics included dementia care, recognizing and reporting elder abuse, and medication training.

During interview on 04/04/2024, Administrator and 6 out of 6 interviewed staff stated the staff are provided with proper training.

See LIC9099-C for more information. Page 1 of 2.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 26-AS-20230327090832

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: DE UN AMOR	FACILITY NUMBER: 445201621
	VISIT DATE: 04/04/2024

NARRATIVE

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The Activity Calendars from March 2023, April 2023, and April 2024 show activities scheduled 5 days per week. The activities include Bingo, exercise, one-man band sing-along, piano man sing-along, and movie and popcorn afternoon.

8 out of 8 interviewed residents, 6 out of 6 interviewed staff, and Administrator Saaj Kaiyom stated during interview that the staff provide residents with activities.

During visit on 04/04/2024, LPA Marrufo observed a pianist entertaining residents in the activity room.

Based on information from interviews conducted with staff, and records reviewed, and observations, although the allegations listed above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are unsubstantiated.

No Deficiencies were cited under California Code of Regulations Title 22.

This report was reviewed with Administrator Saaj Kaiyom and a copy of this report was provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 5