445202888-4-24-2026-26-AS-CKAI-DUFSM8-20260526135929

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445202888
Report Date: 04/24/2026
Date Signed: 04/24/2026 04:25:13 PM

Unfounded

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 AMOR		FACILITY NUMBER:	445202888
ADMINISTRATOR:	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:	04/24/2026
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Marisol Davis		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff did not inform responsible party of facility's refund policy

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Marisol Davis, caregiver. On 03/12/2025, the department received a complaint with the above allegation. On 03/14/2025, LPA Marrufo conducted an initial complaint investigation visit. Additional complaint investigation visits were conducted on 08/12/2025, 02/24/2026, 03/24/2026, and 04/20/2026.

When the department received the complaint, it was alleged that after R1 deceased, facility staff did not inform R1’s family member that R1’s account would be charged a fee for every day that R1’s possessions remained in R1’s former bedroom in the facility.

See LIC9099-C pages for more information. Page 1 of 3.

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2026

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 3

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: 04/24/2026

NARRATIVE

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On 03/14/2025, LPA Marrufo obtained a copy of R1’s Admission Agreement. Page 8 of the Admission Agreement states, “18. Termination of Agreement A. This admission agreement is terminated automatically by the death of the resident. The resident’s relatives and/or responsible persons will not be liable for any payment beyond that due at the time of death unless agreed to in writing. B. [Signature of R1’s Responsible Person, family member FM1] This agreement is terminated upon the death of the resident.”

LPA Marrufo interviewed Licensee Saaj Kaiyom on 03/24/2026. During interview, Licensee stated R1 was admitted to the facility on 02/25/2025. Licensee stated that when he was reviewing R1’s service agreement with FM1, he explained to FM1 that once R1 would become deceased, R1’s monthly rate would be prorated after R1’s belongings were removed from the facility.

Licensee stated on Monday, March 8, 2025, R1 deceased while on hospice care. Licensee stated he communicated with R1’s family member, FM1, that the funeral home had come to pick up R1’s body. Licensee stated FM1 thanked Licensee for the information. Licensee stated on Sunday March 9th, R1’s family member FM2 stated he/she would come to the facility to pick up R1’s belongings that week. Licensee stated FM2 stated he/she may arrive by the end of the week.

Title 22 Regulation 87507 Admission Agreements references Health and Safety Code section 1569.652 (a), (c), and (d):

“(a) A residential care facility for the elderly shall not require advance notice for terminating an admission agreement upon the death of a resident. No fees shall accrue once all personal property belonging to the deceased resident is removed from the living unit.

(c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual, individuals, or entity contractually responsible for the fees or, if the deceased resident paid the fees, to the resident’s estate, within 15 days after the personal property is removed."

Page 2 of 3.

SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 3

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: 04/24/2026

NARRATIVE

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"(d) If fees are assessed while a resident’s personal property remains in a unit after the resident is deceased, a licensee shall, within three days of becoming aware of the resident’s death, provide to the resident’s responsible person, or other individual or individuals as identified in the admission agreement or attachment, written notice of the facility’s policies regarding contract termination upon death and refunds.”

On April 21, 2026, LPA Marrufo obtained screenshots of text messages from a group chat that included Licensees Saaj Kaiyom, Lusanta Kaiyom, S1, FM1, and FM2. In the group chat, Licensee Saaj Kaiyom expresses his condolences for the death of R1 on 03/08/2025. On 03/10/2025, Licensee Saaj Kaiyom sent a text in the group chat stating that once R1’s belongings are removed, he will give a refund check for the following day onward for the remainder of the month.

This agency has investigated the complaint allegation listed. Based on interviews, and review of records, the department has found that the complaint allegation is unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

This report was reviewed with Marisol Davis and a copy of this report was provided.

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END REPORT

SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2026

LIC9099 (FAS) - (06/04)

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