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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 445202888
Report Date: 03/24/2026
Date Signed: 03/24/2026 04:26:11 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
03/12/2025 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20250312153954
FACILITY NAME:DE UN AMORFACILITY NUMBER:
445202888
ADMINISTRATOR:KAIYOM, LUSANTAFACILITY TYPE:
740
ADDRESS:460 EUREKA CANYON RDTELEPHONE:
(210) 724-2751
CITY:CORRALITOSSTATE: CAZIP CODE:
95076
CAPACITY:25CENSUS: 17DATE:
03/24/2026
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Jackie ColoresTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Staff did not observe resident for change in condition
Staff did not seek emergency medical care for resident
INVESTIGATION FINDINGS:
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LPA Marrufo conducted an unannounced complaint investigation visit and met with Jackie Colores, staff. On 03/12/2025, the Department received a complaint with the above allegations. On 03/14/2025, LPA Marrufo conducted an initial complaint investigation visit. Additional complaint investigation visits were conducted on 08/12/2025 and 02/24/2025.

Allegation: Staff did not observe resident for change in condition

During interview with a department investigator on 09/08/2025, staff S1 stated that on 03/04/2025, S1 arrived in R1’s bedroom. S1 stated that R1 would use a white board to communicate his/her needs. S1 stated S1 showed R1 the white board, but R1 did not respond. S1 stated R1 “looked off.” S1 did not recall if R1 had facial drooping or signs of a stroke. S1 told S3 about R1’s change in condition.

See LIC9099-C page for more information. Page 1 of 3.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 26-AS-20250312153954
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: 445202888
VISIT DATE: 03/24/2026
NARRATIVE
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During interview on 08/26/2025, a department investigator interviewed S2. S2 stated that while S2 was walking past R1 in the common area, S2 noticed that R1 looked disoriented and was not looking at his/her personal companion while his/her personal companion was talking to him/her. S2 observed R1 in the dining room area. S2 observed R1 to be slouched to his/her side, not eating, and not taking his/her medication. S2 stated R1’s face did not appear to be drooping. S2 stated to have told S3 about R1’s change in condition.

During interview with a department investigator on 08/26/2025, S3 stated that on 03/04/2025 at around 8:30 AM, R1 was brought to the dining room table for breakfast and medications. S3 stated that S2 asked S3 to check on R1. S3 used the whiteboard to ask R1 if R1 was okay, and R1 nodded his/her head to indicate he/she was okay. S3 used the whiteboard to ask R1 if he/she was in pain or if he/she needed an ambulance, and R1 responded no. There were no physical assessments like range of motion, skin checks, or alertness that were completed at that time. S3 called R1’s family member FM1 to ask FM1 if R1’s behavior was normal. FM1 stated to not know if R1’s behavior was normal, so FM1 asked S3 to have staff monitor R1 and wait until R1’s other family member, FM2, could arrive at the facility and assess R1. S3 continued to monitor R1 from 8:30 AM to 12:30 PM, when emergency response personnel arrived. S3 stated that R1 was still able to answer yes or no questions until emergency response personnel arrived.

Allegation: Staff did not seek emergency medical care for resident

On 03/04/2025, at about 7:30 AM, staff S2 reported that he/she thought resident R1 appeared “off” to S3. S3 was unsure if R1 was at baseline, so he/she communicated to R1’s Family Member, FM1. FM1 was unsure if R1 was at baseline because R1 had a history of irregular mood changes.

FM1 advised staff to wait for R1’s other family member, FM2, to assess R1 so they could decide whether to call 911. From 8:30 AM to 12:30 PM, S3 monitored R1 until FM2 arrived at the facility. Upon FM2’s assessment, FM2 directed staff to call 911. S3 called 911 at 12:30 PM.


Page 2 of 3.
SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 26-AS-20250312153954
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: 445202888
VISIT DATE: 03/24/2026
NARRATIVE
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Prior to FM2’s arrival, R1 did not report to be in pain nor did S3 observe R1 to exhibit life-threatening symptoms.

S3 stated during interview that if R1 had become non-responsive or showed obvious signs of decline, he/she would have bypassed FM1’s instructions and called 911.

At the hospital, R1 was determined to have had a mild stroke. R1’s medical records corroborate that R1’s stroke may not have been obvious at the time of the incident.

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 violations did or did not occur. Therefore, the allegations are unsubstantiated.

No Deficiencies were cited under California Code of Regulations Title 22

This report was reviewed with Jackie Colores, staff, and a copy of this report was provided.

Page 3 of 3.



END REPORT
SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 6
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
03/12/2025 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20250312153954

FACILITY NAME:DE UN AMORFACILITY NUMBER:
445202888
ADMINISTRATOR:KAIYOM, LUSANTAFACILITY TYPE:
740
ADDRESS:460 EUREKA CANYON RDTELEPHONE:
(210) 724-2751
CITY:CORRALITOSSTATE: CAZIP CODE:
95076
CAPACITY:25CENSUS: 17DATE:
03/24/2026
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Jackie ColoresTIME COMPLETED:
04:45 PM
ALLEGATION(S):
1
2
3
4
5
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8
9
Staff did not follow resident's hospice care plan
INVESTIGATION FINDINGS:
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When the Department received the complaint, it was alleged that facility staff were not administering medication M3 to resident R1.

On 08/12/2025, LPA Marrufo interviewed staff S3. During interview, S3 stated the facility staff followed R1’s hospice care plan. S3 stated R1’s Hospice Care Agency prohibits facility staff from administering M3 to R1.

On 03/14/2025, LPA Marrufo obtained a copy of R1’s Hospice Care Plan. The Hospice Care Plan states M3 is included in R1’s Comfort Pak. The Hospice Care Plan instructs staff to call the Hospice Care Agency to initiate any Comfort Pak.


See LIC9099-C page for more information. Page 1 of 2.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 26-AS-20250312153954
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: 445202888
VISIT DATE: 03/24/2026
NARRATIVE
1
2
3
4
5
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This agency has investigated the complaint allegations listed. Based on interviews, review of records, the CCLD has found that the complaint allegations are UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

This report was reviewed with Jackie Colores, staff, and a copy of this report provided.

Page 2 of 2.

END REPORT
SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 6