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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 445202888
Report Date: 04/20/2026
Date Signed: 04/20/2026 04:42:16 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: 20DATE:
04/20/2026
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Lusanta KaiyomTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Staff did not distribute resident's medication as prescribed
Staff did not ensure that resident was provided a signal system specific to living unit
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Lusanta and Saaj Kaiyom. 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, 02/24/2025, 03/24/2026.

Allegation: Staff did not distribute resident's medication as prescribed

When the department received the complaint, it was alleged that the facility did not administer R1’s medications M1 and M2 as prescribed.

See LIC9099-C pages 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: 04/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2026
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 7
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: 04/20/2026
NARRATIVE
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On 02/24/2026, LPA Marrufo interviewed staff S1, who stated that there were no issues with distributing M1 and M2 to R1 as prescribed. S1 stated there was a doctor’s order to increase R1’s dosage of M1 from a quarter tablet to a full tablet.

R1’s Admission Agreement indicates R1’s admission date is 02/25/2025.

R1’s Medication Administration Record (MAR) indicates R1 was prescribed a whole tablet of M1 from 02/25/2025 to 03/04/2025. R1’s MAR states R1 was assisted with the administration of a full tablet of M1 from 02/25/2025 to 03/04/2025.

R1’s MAR indicates R1 was prescribed a quarter tablet of M1 from 02/25/2025 to 03/07/2025. R1’s MAR indicates R1 was assisted with the administration of a quarter tablet of M1 from 03/04/2025 to 03/07/2025. The boxes for 03/01/2025 to the morning of 03/04/2025 have an “x” in them, meaning the resident was not present at the facility when the medication was prescribed to be given.

On 03/25/2026, LPA Marrufo received a copy of a prescription order for R1. The prescription order called for a quarter tablet of M1. The prescription order did not have a date on it.

Allegation: Staff did not ensure that resident was provided a signal system specific to living unit

During visit on 08/12/2025, LPA Marrufo toured the bedroom that R1 lived in when R1 lived at the facility. LPA Marrufo pushed the Emergency Call Button which was installed on the bedroom wall near the bed. Within 3 minutes, a staff member came to the bedroom to check on the emergency call.

LPA Marrufo then went into the kitchen area where there was a panel that showed the emergency call came from R1’s former bedroom.

LPA took photographs of the Emergency Call Button in the bedroom and the panel in the kitchen area.

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

DATE: 04/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 7
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: 04/20/2026
NARRATIVE
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During visit on 03/24/2026, LPA Marrufo obtained a copy of a document titled “Call Button Room Numbers.” The document was placed in a plastic sheet protector pinned to the wall near the call button panel in the kitchen area. The document listed R1’s first name as the resident in R1’s bedroom.

During visit on 03/24/2026, LPA Marrufo interviewed Licensee Saaj Kaiyom and staff S1.

During interview, Licensee stated the emergency call system does not have a log.
During interview, S1 stated that R1 could not independently trigger his/her emergency pendant. S1 stated R1’s private care giver would trigger R1’s pendant. S1 stated whenever R1’s emergency pendant was pressed, the emergency pendant would cause R1’s room number to show up on the emergency panel on the kitchen area wall. S1 stated there was never a time when R1's pendant was pressed and a staff went to the wrong room in response.

Based on information from interviews conducted with staff, records reviewed, and observations, 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 Saaj Kaiyom 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: 04/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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: 20DATE:
04/20/2026
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Lusanta KaiyomTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Staff did not follow resident's dietary plan
INVESTIGATION FINDINGS:
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When the department received the complaint, it was alleged that staff served R1 meals containing wheat.

R1’s Physician’s Report states R1 has a special diet due to celiac disease. WebMD.com defines celiac disease as, “an autoimmune disorder that’s triggered when you eat gluten, a protein found in wheat, barley, and other grains.” The Allergies section of R1’s Physician’s Report states, “Gluten allergy due to celiac disease…someone needs to prepare gluten-free meals.” The Other Conditions section of R1’s Physician’s Report states, “Celiac disease (gluten free diet mandatory).”

During visit on 03/24/2026, LPA Marrufo conducted interviews with Licensee Saaj Kaiyom and staff S1.

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

DATE: 04/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
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: 04/20/2026
NARRATIVE
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During interview, Licensee Saaj Kaiyom stated that R1 had a gluten free diet. Licensee stated that facility staff served R1 gravy made with Campbell Cream of Mushroom soup while R1’s family member was visiting R1. Campbells.com states Cream of Mushroom Soup ingredients include wheat. Licensee stated that R1’s family member prevented R1 from consuming the gravy made from Campbell Cream of Mushroom soup.

During interview, S1 stated to have notified the rest of the staff, including the cooks, that R1 was not to have anything with lactose. S1 stated the facility cooks did not realize Campbell Cream of Mushroom soup contained lactose. S1 stated staff served R1 Campbell Cream of Mushroom soup, but R1’s private care giver notified staff and the soup was removed.

Based on records review and interviews, there is preponderance of evidence to prove the alleged violation did occur. Therefore, the allegation is substantiated.

See LIC9099-D for deficiencies cited per the California Code of Regulations, Title 22.

This report was reviewed with Saaj Kaiyom and a copy of this report and appeal rights were provided.

Page 2 of 2.

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

DATE: 04/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 7
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/20/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/21/2026
Section Cited
CCR
87555(b)(7)
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87555(b)(7) General Food Service Requirements (b) The following food service requirements shall apply: (7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement was not met as evidenced by: Licensee did not ensure
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Licensee agrees to submit a Plan of Correction by 04/21/2026 stating how the licensee shall ensure that residents’ modified diets are provided, including by conducting in-service training of staff on providing modified diets to residents who require them.
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that R1’s modified diet prescribed by his/her physician as a medical necessity was provided; staff provided R1 with a meal containing wheat, despite R1’s physician prescribing a special diet due to celiac disease, which poses an immediate health risk to residents in care.
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Once training is completed, Licensee shall submit training rosters including names of staff trained, training dates, training topics, and names and qualifications of trainers.
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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.
SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 7