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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202599
Report Date: 09/15/2021
Date Signed: 09/16/2021 04:50:12 PM

COMPREHENSIVE INSPECTION
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:DIYA SENIOR CARE HOMEFACILITY NUMBER:
435202599
ADMINISTRATOR:KAUR, BHUPINDERFACILITY TYPE:
740
ADDRESS:276 CLEARPARK CIRCLETELEPHONE:
(408) 629-0388
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY:6CENSUS: 6DATE:
09/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:35 PM
MET WITH:Bhupinder Kaur, ADMTIME COMPLETED:
04:35 PM
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At 3:35PM, Licensing Program Analyst (LPA) Steve Chang arrived at the facility, and met with administrator (ADM) Bhupinder Kaur. ADM conducted an infection control/prevention screening, and took LPA body temperature, then log LPA into the guest log book.

LPA toured the faculty with ADM inside out. There are 3 client shared rooms, 2 restrooms at the first floor. There are two staff live-in rooms, one restroom, and ADM's office room on the second floor. LPA inspected kitchen, living room, and dinning room. LPA observed 6 clients (C1 - C6) in the facility. LPA observed another staff (S1) in the facility. The beds in the shared rooms were observed 6 feet apart. LPA inspected the food supplies, Two days perishable foods and seven non perishable foods were observed sufficient. Fire extinguisher's date was observed valid.

Not all the trash cans were with covers in facility. ADM stated the facility will replace them to be trash cans with covers. LPA observed no paper towel with holder in the kitchen. ADM stated the facility will fix this issue with 3 days.

The current roasters of staff and clients were obtained. Medication closet was observed locked. LPA inspected the PPE supplies. PPE supplies were observed sufficient.
LPA discussed and reviewed LIC808, mitigation plan, with ADM. ADM stated the facility will follow the COVID protocol.

No citation was issued for today's inspection. Exit interview was conducted with ADM. This report was provided to ADM to review and to sign. A copy of this report was emailed to ADM.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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