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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
445202888
Report Date:
04/04/2024
Date Signed:
04/04/2024 04:46:56 PM
Document Has Been Signed on
04/04/2024 04:46 PM
- 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 AMOR
FACILITY NUMBER:
445202888
ADMINISTRATOR/
DIRECTOR:
KAIYOM, LUSANTA
FACILITY TYPE:
740
ADDRESS:
460 EUREKA CANYON RD
TELEPHONE:
(210) 724-2751
CITY:
CORRALITOS
STATE:
CA
ZIP CODE:
95076
CAPACITY:
25
CENSUS:
19
DATE:
04/04/2024
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:
Saaj Kaiyom
TIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) David Marrufo conducted a Case Management Visit and met with Administrator Saaj Kaiyom.
The purpose of the visit was to amend a report previously delivered on 10/24/2023 to change the visit type from a Required - 1 Year visit to a Pre-Licensing visit.
No deficiencies were cited at this time as per California Code of Regulations Title 22.
This report was reviewed with Administrator Saaj Kaiyom and a copy of the report was provided.
SUPERVISORS NAME
:
Sarah Yip
LICENSING EVALUATOR NAME
:
David Marrufo
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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