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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 445202888
Report Date: 04/24/2026
Date Signed: 04/24/2026 04:20:43 PM

Substantiated


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
08/04/2025 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20250804193213
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: 19DATE:
04/24/2026
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Marisol DavisTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff withholding resident's records from resident's responsible party.
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 08/04/2025, the department received a complaint with the above allegation. On 08/12/2025 and 02/24/2026, LPA Marrufo conducted additional complaint investigation visits.

When the department received the complaint, it was alleged that attorneys
of R1’s family member, FM1 requested R1’s resident records and the facility did not provide FM1 with R1’s resident records.

During visit on 08/12/2025, LPA Marrufo obtained a copy of R1’s Admission Agreement. R1’s Admission Agreement is dated 02/25/2025. R1’s Admission Agreement is initialed and signed by R1’s family member FM2.

See LIC9099-C pages for more information. Page 1 of 3.
Substantiated
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 4
Control Number 26-AS-20250804193213
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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During visit on 08/12/2025, LPA Marrufo obtained a copy of R1’s Physician’s Report. R1’s Physician’s Report has FM1’s name and signature in the “Signature of Resident and/or Resident’s Legal Representative” section. FM2’s signature is dated 02/07/2025.

On 09/05/2025, LPA Marrufo obtained copies of written communications sent from FM1’s attorney’s office to the facility’s attorney’s office. On 06/10/2025, FM1’s attorneys’ office sent an email to the facility’s attorney’s office requesting all R1’s billing, medical, and resident records. The email requested that the records be made available no later than 06/24/2025. On 07/31/2025, FM1’s attorneys’ office sent an email to the facility’s attorney’s office asking if the facility’s attorneys’ office will be providing R1’s resident records. On 08/29/2026, the facility’s attorneys’ office sent an email to FM1’s attorneys’ office stating that the facility will provide the records “after the weekend.” On 09/04/2025, FM1’s attorney’s office sent an email to the facility’s attorney’s office stating that they had still not received R1’s resident records.

On 02/24/2026, LPA Marrufo obtained a copy of R1’s Attorney’s Certificate. The document states that R1’s Power of Attorney was executed on 06/04/2022. The document states that R1’s named Attorney in Fact is family member FM2 or FM1.

On 02/24/2026, LPA Marrufo obtained a copy of R1’s Financial Durable Power of Attorney. The document is dated 06/04/2022. The document states, “I, [R1], hereby appoint [FM2] OR [FM1] as my attorney in fact, to act for me and in my name, as authorized in this document. I intend either agent to be able to act for me independently.” The document further states, “Subject to any limitations in this document, I hereby grant to my agent(s) full power and authority to act for me and in my name in any way which I myself could act, if I were personally present and able to act, with respect to the following matters as each of them is defined and construed by the laws of the State of California:…18. Any third party from whom the agent may request information, records, or other documents regarding the principal’s personal affairs may release and deliver all such information, records, or documents to the agent. The principal hereby waives any privilege that may apply to release of such information, records, or other documents.”


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 4
Control Number 26-AS-20250804193213
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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Based on records review and interviews, there is preponderance of evidence to prove the alleged violations did occur. Therefore, the allegation is substantiated.

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

This report was reviewed with Marisol Davis, caregiver, and a copy of this report and appeal rights were provided.

Page 3 of 3.



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)
Page: 3 of 4
Control Number 26-AS-20250804193213
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: 04/24/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/01/2026
Section Cited
CCR
87468.2(a)(19)
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87468.2(a)(19) Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of
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Licensee agrees to submit proof that the facility has submitted R1’s financial, medical, and resident records to the attorneys’ office representing FM1 by Plan of Correction due date of 05/01/2026.
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the following personal rights: (19) To have prompt access to review all of their records and to purchase photocopies of their records. Photocopied records shall be provided within two (2) business days and at a cost that does not exceed the community standard for photocopies.

This requirement was not met as evidenced by: Licensee did not ensure that resident R1’s Power Of Attorney and Responsible Person, FM1, received copies of R1’s billing, medical, and resident records as requested by FM1’s attorneys’ office on behalf of FM1, which poses a potential personal rights risk to residents in care.
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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.
SUPERVISOR'S NAME: Christine Kabariti
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 4