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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202888
Report Date: 10/06/2023
Date Signed: 04/04/2024 04:45:10 PM


Document Has Been Signed on 04/04/2024 04:45 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 04/03/2024 09:15 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

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** Amended on 04/04/2024 to state that the visit was conducted as a Pre-Licensing visit, not a Required 1 Year visit **** 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. Upon review of records, LPAs observed that the medication was not recorded in the resident's Centrally Stored Medication Log. 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 YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (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.

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: 445202888
VISIT DATE: 10/06/2023
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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.

LPAs reviewed Component III presentation with Administrator Saaj Kaiyom.

This report was reviewed with Saaj Kaiyom 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: 10/06/2023
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)
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