445201621-10-24-2023-26-AS-DMAO-CWD2GJ-20231006172313

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 445201621
Report Date: 10/06/2023
Date Signed: 10/24/2023 12:00:12 PM

Document Has Been Signed on 10/24/2023 12:00 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 10/24/2023 08:58 AM

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

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	Amended on 10/24/2023 to state that the visit was conducted as a Required 1 Year visit, not a complaint visit Licensing Program Analysts (LPAs) David Marrufo and Davide Hailu conducted an unannounced Required 1 Year visit and met with Administrator Saaj Kaiyom. During visit, LPAs observed the facility inside and out. LPAs observed the facility kitchen area and observed the facility had locked cabinets for storing sharps and cleaning supplies. LPAs observed the facility food supply and observed a perishable food supply of at least 2 days and a non-perishable food supply of at least 7 days. LPAs observed the first aid kit was complete. LPAs observed 17 out of 17 resident rooms. LPAs observed resident R1's bedroom had a bottle of prescription medication on R1's dresser drawer. LPAs observed resident R2 had a bottle of Tylenol in an unsecured dresser drawer. The Physician's Reports for both R1 and R2 indicated that they are not able to manage their own medications. LPAs observed unsecured sharp objects in resident R3 and R4's bedrooms. LPAs measured the water temperatures in 4 out of 4 bathrooms and the water temperatures measured between 114-119 F. LPAs tested the facility smoke alarms and carbon monoxide detectors and found them to be functional when tested. LPAs toured the outside area and found the outside deck area and roof had been reconstructed. LPAs observed the outdoor exits were clear of obstructions. LPAs reviewed resident and staff records. Staff S1 was missing an LIC501 Health Screening form. R1 had a medication that was missing a prescription label. See LIC809-C for more information.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023

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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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: DE UN AMOR	FACILITY NUMBER: 445201621
	VISIT DATE: 10/06/2023

NARRATIVE

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During visit, LPAs were in an activity room observing residents with staff S2 when they observed another staff leave the residents to get a resident a snack without endorsing the supervision of the residents to S2.

An Advisory Notes was Issued. See LIC9102 for more information.

Deficiencies were cited as per California Code of Regulations Title 22. See LIC809-D for more information.

This report was reviewed with Saaj Kaiyom and a copy of the 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: 10/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

LIC809 (FAS) - (06/04)

Page: 2 of 5

Document Has Been Signed on 10/24/2023 12:00 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 10/24/2023 09:02 AM

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: DE UN AMOR	FACILITY NUMBER: 445201621
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(1)B)

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (1) Medications shall be centrally stored under the following circumstances: (B) Any medication is determined by the physician to be hazardous if kept in the personal possession of the person for whom it was prescribed. This requirement is not met as evidenced by: Licensee did not ensure that residents R1 and R2 did not have prescription medications unsecured in their resident living units, which poses an immediate safety risk to residents in care.
	Deficient Practice Statement
1 2 3 4	Licensee did not ensure that residents R1 and R2 did not have prescription medications unsecured in their resident living units, which poses an immediate safety risk to residents in care. Amended on 10/24/2023 to edit the Deficient Practice Statement
	POC Due Date: 10/07/2023
	Plan of Correction
1 2 3 4	Licensee agrees to submit a Plan of Correction by POC date to ensure that there are no unsecured medications in resident living units and staff are trained to prevent medications from being left unsecured in resident living units. Licensee agrees to submit copies of training records to CCL once training is completed.

Type A

Section Cited

CCR

87705(f)(1)

Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by: Licensee did not ensure that residents R3 and R4 did not have unsecured sharp objects in their bedrooms, which poses an immediate safety risk to residents in care.
	Deficient Practice Statement
1 2 3 4	Licensee did not ensure that residents R3 and R4 did not have unsecured sharp objects in their bedrooms, which poses an immediate safety risk to residents in care. Amended on 10/24/2023 to edit the Deficient Practice Statement
	POC Due Date: 10/07/2023
	Plan of Correction
1 2 3 4	Licensee agrees to submit a Plan of Correction by POC date to ensure that there are no unsecured sharp objects in resident living units and staff are trained to prevent sharp objects from being stored in resident living units. Licensee shall submit training records to CCL once training is completed.

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: 10/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 10/24/2023 12:01 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 10/24/2023 09:07 AM

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: DE UN AMOR	FACILITY NUMBER: 445201621
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(e)(1-4)

87465 Incidental Medical and Dental Care (e)(1-4): For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. (1) The specific symptoms which indicate the need for the use of the medication. (2)The exact dosage. (3) The minimum number of hours between doses. (4) The maximum number of doses allowed in each 24-hour period. This requirement is not met as evidenced by: Licensee did not ensure that R1 had a medication with a prescription label, which poses a potential safety risk to residents in care.
	Deficient Practice Statement
1 2 3 4	Licensee did not ensure that R1 had a medication with a prescription label, which poses a potential safety risk to residents in care. Amended on 10/24/2023 to edit the Deficient Practice Statement
	POC Due Date: 10/13/2023
	Plan of Correction
1 2 3 4	Licensee agrees to audit all resident medications and ensure that all medications have a prescription label by POC date. Licensee agrees to submit photographic evidence of R1's medication with a prescription label and a statement of completion that all medications have been reviewed and have medication labels by POC date.

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: 10/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 10/24/2023 12:02 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 10/24/2023 09:08 AM

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: DE UN AMOR	FACILITY NUMBER: 445201621
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)(11)

Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements – General. This requirement is not met as evidenced by: Licensee did not ensure that staff S1 had a LIC503 Health Screening Form in S1's staff record, which poses a potential safety risk to residents in care.
	Deficient Practice Statement
1 2 3 4	Licensee did not ensure that staff S1 had a LIC503 Health Screening Form in S1's staff record, which poses a potential safety risk to residents in care. Amended on 10/24/2023 to edit the Deficient Practice Statement
	POC Due Date: 10/13/2023
	Plan of Correction
1 2 3 4	Licensee agrees to ensure that all staff have LIC503 Health Screening forms in their staff records and submit a statement of completion and a copy of S1's completed Health Screening Form by POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 10/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023

LIC809 (FAS) - (06/04)

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