445201621-11-17-2023-26-AS-KHOS-D2LVRP-20240219154016

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445201621
Report Date: 11/17/2023
Date Signed: 11/17/2023 03:35:20 PM

Unsubstantiated

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
11/15/2023 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20231115102806

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: 20	DATE:	11/17/2023
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Saaj Kaiyom		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff did not treat resident with respect

INVESTIGATION FINDINGS:

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

During visit, LPA Marrufo interviewed Saaj Kaiyom and staff S1-S5 and obtained copies of R1's Physician's Report and Appraisal/Needs and Services Plan.

R1's Physician's Report states R1 does not have Mild Cognitive Impairment or Dementia. R1's Physician's Report states R1 has Intermittent Confusion/Disorientation.

During Interview, Saaj Kaiyom stated R1 has been transferred to another facility and R1 calls the facility multiple times a day since R1 has moved out. See LIC9099-C for more information.

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: 11/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2023

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

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20231115102806

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: 11/17/2023

NARRATIVE

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Mr. Kaiyom states R1 calls the facility multiple times per day ever since R1 has moved out of the facility to inquire about R1's mail. Mr. Kaiyom states that each time he speaks with R1, he informs R1 that he is storing R1's mail and has the mail available any time R1 or R1's family member want to retrieve the mail.

Mr. Kaiyom stated during interview to have never hung up the phone or cut a call short with R1.

During interview, staff S1-S5 stated to have never hung up the phone on anyone. Staff S1, S2, and S3 stated to have received telephone calls from R1 and R1 asked them about R1's mail. S1, S2, and S3 stated to have never hung up the phone on R1 or cut a call short and to have always said goodbye before hanging up.

LPA Marrufo reviewed the facility telephone call log on the cordless facility telephone. The telephone call log did not have any telephone numbers associated to R1 or show R1's name. The telephone call log had multiple instances of "Wireless Number" shown, but it did not indicate the name or telephone number of the caller.

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

No Deficiencies cited under California Code of Regulations Title 22

This report was reviewed with 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: 11/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2023

LIC9099 (FAS) - (06/04)

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