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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445201621
Report Date: 10/24/2023
Date Signed: 10/24/2023 11:54:22 AM


Document Has Been Signed on 10/24/2023 11:54 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:DE UN AMORFACILITY NUMBER:
445201621
ADMINISTRATOR:FLETES, MARICELAFACILITY TYPE:
740
ADDRESS:460 EUREKA CANYON ROADTELEPHONE:
(831) 728-0303
CITY:CORRALITOSSTATE: CAZIP CODE:
95076
CAPACITY:25CENSUS: 21DATE:
10/24/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Betsy TorresTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Betsy Torres. The purpose of the visit was to follow up with the deficiencies that were cited during the last visit that occurred on 10/06/2023.

During visit, LPA Marrufo toured 16 out of 16 resident bedrooms and did not observe any sharp objects. LPA Marrufo observed a prescription medication unsecured in resident R1's living unit.

LPA Marrufo reviewed 6 resident medications and did not observe any medications without a prescription label.

LPA Marrufo was not able to review staff records during visit due to the staff records being locked in a cabinet and the keys were not on the facility premises during visit.

An Advisory Note was issued. See LIC9102 for more information.

A deficiency was cited as per California Code of Regulations Title 22. See LIC809-D page for more information. A civil penalty will be assessed today for $250 for a repeat violation.

This report was reviewed with Betsy Torres and a copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (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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Document Has Been Signed on 10/24/2023 11:54 AM - It Cannot Be Edited

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: 10/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/25/2023
Section Cited
CCR
87465(h)(1)B)

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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
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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.
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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. ** A civil penalty of $250 is being assessed today for a repeat violation **
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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: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (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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