De Un Amor

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management - Legal/Non-compliance visit and met with Jackie Colores. The purpose of the visit was to review the following Plan of Action as agreed upon during the Non-Compliance Conference visit that occurred on 06/15/2026: Licensee shall develop a written plan of action describing the facility’s procedures when resident(s) are prescribed a modified diet prescribed by the resident’s physician as a medical necessity. This plan shall include annual training with staff and training records must be retained for licensing review upon request. During visit, LPA Marrufo obtained a copy of the resident restricted diet list that is posted inside the facility kitchen. The list details the resident food allergies and food restrictions to staff. LPA reviewed the resident records to verify that the residents had food restrictions that matched the resident restricted diet list. LPA Marrufo interviewed staff S1, who works in the facility kitchen as a cook. S1 was able to recite and explain the dietary needs and restrictions of the residents. LPA reviewed the facility food supplies in the kitchen and pantry areas during visit. LPA Marrufo requests that staff training records in regards to resident diets are submitted to the department by 09/17/2026. No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Jackie Colores and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 10, 2026

Type of visit: Office

On 06/15/2026, San Bruno Regional Office-San Jose Unit conducted a non-compliance conference meeting with Licensee Lusanta Kaiyom and Administrator (ADM) Saaj Kaiyom, and Attorney Ryan Keever via Teams meeting. Present in the meeting were Regional Manager (RM) Jackie Jin, Licensing Program Manager (LPM) Christine Kabariti, and Licensing Program Analysts (LPAs) Marcella Tarin and Marcela Yanez. During the non-compliance meeting, the following serious violations were discussed 7555(b)(7) - General Food Service Requirements. During this meeting, the compliance plan was developed and discussed with the licensee which includes more frequent monitoring inspection visits to ensure compliance with this compliance plan and Title 22 Regulations for 2 years. Licensee was provided the link below for resources and guidance to improve facility operations: https://www.cdss.ca.gov/inforesources/community-care/resource-guide-for-providers. This report was reviewed with Licensee Lusanta Kaiyom and Administrator (ADM) Saaj Kaiyom. A copy of this report was provided to Licensee and ADM.the state’s words, verbatim · CDSS document, Jun 15, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year Visit and met with Lusanta Kaiyom, Licensee/Administrator. During visit, LPA Marrufo toured the facility inside and out. LPA observed the kitchen area and the pantry area. LPA observed there to be a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA toured the resident rooms. Each bedroom had working lights and available bedding. During visit, staff triggered the smoke detectors and carbon monoxide detectors in the facility bedrooms and hallways. All detectors functioned properly when tested. LPA toured five resident bathrooms. Each bathroom had working lights and available soap and paper towels. The water temperatures in the bathrooms ranged form 105 F to 119 F. LPA toured the outside area of the facility and observed it to be clear of obstructions. LPA reviewed six resident records, including Centrally Stored Medications and Destruction Records. All six resident records were complete. LPA reviewed six staff records. All staff records were complete. See LIC809-C page for more information. Page 1 of 2. LPA Marrufo requests that the following documents be updated and copies sent to the department by 05/12/2026: LIC500 Personnel Report LIC308 Designation of Administrative Responsibility LIC400 Affidavit Regarding Client/Resident Cash Resources LIC610E Emergency Disaster Plan No deficiencies were cited as per California Code of Regulations Title 22. This report was reviewed with Licensee/Administrator Lusanta Kaiyom and a copy of this report was provided. Page 2 of 2. END REPORTthe state’s words, verbatim · CDSS document, May 5, 2026

Allegation investigated: Staff withholding resident's records from resident's responsible party.

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 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. 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 REPORTthe state’s words, verbatim · CDSS document, Apr 24, 2026 · control 26-AS-20250804193213

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(19) · Plan of correction due date: May 1, 2026

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 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.the state’s words, verbatim · CDSS document, Apr 24, 2026

Plan of correction: 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.

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

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 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. "(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. Page 3 of 3. END REPORTthe state’s words, verbatim · CDSS document, Apr 24, 2026 · control 26-AS-20250312153954

Allegation investigated: Staff did not distribute resident's medication as prescribed Staff did not ensure that resident was provided a signal system specific to living unit

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 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. 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 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 REPORTthe state’s words, verbatim · CDSS document, Apr 20, 2026 · control 26-AS-20250312153954

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(7) · Plan of correction due date: Apr 21, 2026

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 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.the state’s words, verbatim · CDSS document, Apr 20, 2026

Plan of correction: 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. Once training is completed, Licensee shall submit training rosters including names of staff trained, training dates, training topics, and names and qualifications of trainers.

The state marks this report as 7 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Allegation investigated: Staff did not observe resident for change in condition Staff did not seek emergency medical care for resident

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 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. 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 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 REPORTthe state’s words, verbatim · CDSS document, Mar 24, 2026 · control 26-AS-20250312153954

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Administrator Lusanta Kaiyom. During visit, LPA Marrufo toured the facility inside and out. LPA toured the kitchen area and observed there to be locked storage areas for sharp objects and another locked storage area for cleaning supplies. LPA reviewed the first aid kit and found it to be complete. LPA toured the food supply in the kitchen and in the facility basement and observed there to be a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA toured four out of four resident bathrooms. Each bathroom had working lights and available soap and paper towels. The water temperatures in the bathroom sinks ranged from 111 F to 119 F. LPA toured the facility hallways and resident rooms. LPA tested the facility smoke detector system and found it to function properly when tested. Each bedroom had working lights and available bedding and clothing storage areas. LPA toured the outside area and found the exits to be clear of obstructions. LPA reviewed five resident records, including Centrally Stored Medication and Destruction Records, and found them to be complete. LPA reviewed five staff records and found them to be complete. The last recorded emergency disaster drill was conducted on 04/16/2025. No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Administrator Lusanta Kaiyom and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 30, 2025

Type of visit: Case Management - Other

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.the state’s words, verbatim · CDSS document, Apr 4, 2024