435202599-11-21-2022-26-AS-RMAO-CLE6CG-20221121194130

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202599
Report Date: 11/18/2022
Date Signed: 11/21/2022 08:14:48 AM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
04/22/2022 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20220422092403

FACILITY NAME:	DIYA SENIOR CARE HOME		FACILITY NUMBER:	435202599
ADMINISTRATOR:	KAUR, BHUPINDER		FACILITY TYPE:	740
ADDRESS:	276 CLEARPARK CIRCLE		TELEPHONE:	(408) 629-0388
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95136
CAPACITY:	6	CENSUS: 6	DATE:	11/18/2022
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Bani Kaur		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Resident sustained a fracture while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced complaint visit today to deliver the investigation findings of the above allegations and met with Administrator (ADM) Bani Kaur.

On 4/22/2022, the Department received a complaint that the facility resident sustained a fracture while in care.

On the same day, LPA conducted initial 10 day inspection/investigation, and met with ADM, staff and residents. LPA obtained the following facility records: resident's physician report, appraisal needs and service plan, admission agreement, medical records, and incident reports.

Continued on 9099-C. Page 1 of 2.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2022

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-20220422092403

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 HOME	FACILITY NUMBER: 435202599
	VISIT DATE: 11/18/2022

NARRATIVE

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Resident sustained a fracture while in care:
On 4/22//2022, the Department reviewed R1's incident reports (IRs) dated 4/16/2022 and 4/18/2022, R1 had two separate fall accidents in the facility on 4/16/2022 and 4/18/2022. According to IRs, on 4/16/2022 R1 lost his/her balance and fell in the restroom. R1 was immediately sent to hospital, and was discharged on the same day. While on 4/18/2022, R1 attempted to pick up his/her water bottle from bed side, and fell on the floor and hurt his/her lower back. R1 was immediately sent to the hospital.

On 6/13/2022, the Department obtained hospital medical records of R1. Based on medical record reviews, R1 had prior lumbar injuries. Based on R1's appraisal, R1 was ambulatory with no need for assistance.

On 8/4/2022, LPA interviewed ADM, and two staff (S1, S2). All of them stated R1 had falls on 4/16/2022 and 4/18/2022, and was sent to hospital. ADM and S1 stated R1 had Lumbar injuries before R1 was admitted in the facility.

Based on records reviewed and interviews conducted, R1 had lumbar injuries prior admission to the facility. R1 was ambulatory with no need for assistance for walking. The two fall incidents were un-witnessed, it happened in the restroom and in R1's bedroom.

The Department has investigated the above allegations. Based on the investigation, observations, records reviewed, and interviews conducted, the Department found that the above allegations are UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis.

No citations noted at today’s compliant investigation visit. Exit interview was conducted with ADM. This report was provided to ADM for signature.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
04/22/2022 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20220422092403

FACILITY NAME:	DIYA SENIOR CARE HOME		FACILITY NUMBER:	435202599
ADMINISTRATOR:	KAUR, BHUPINDER		FACILITY TYPE:	740
ADDRESS:	276 CLEARPARK CIRCLE		TELEPHONE:	(408) 629-0388
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95136
CAPACITY:	6	CENSUS: 6	DATE:	11/18/2022
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Bani Kaur		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Facility is not sanitary.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced complaint visit today to deliver the investigation findings of the above allegations and met with Administrator (ADM) Bani Kaur.

On 4/22/2022, the Department received a complaint that the facility is not sanitary.

On the same day, LPA conducted initial 10 day inspection/investigation, and met with ADM, staff and residents. LPA obtained the following facility records: resident's physician report, appraisal needs and service plan, admission agreement, medical records, and incident reports.

Continued on 9099-C. Page 1 of 2.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 26-AS-20220422092403

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 HOME	FACILITY NUMBER: 435202599
	VISIT DATE: 11/18/2022

NARRATIVE

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Facility is not sanitary:
On 08/04/2022, LPA conducted an investigation/inspection visit of the facility. During visit, LPA toured and inspected the following areas in the facility: living room, dining room, kitchen, 3 bedrooms and 2 bathrooms.
During the inspection, LPA did not observe feces on the wall of residents' bedrooms. LPA observed bedrooms with no feces or smell.

On 8/04/2022, LPA interviewed staff (S1) and 5 residents (R1 - R5). S1 stated the facility staff check and clean the resident bedrooms everyday. S1 denied there were feces on the wall of residents' bedrooms on 4/16/2022. All of 5 residents did not complain that the facility was unsanitary.

Based on investigation, observations, and interviews conducted, the Department found that the above allegation is UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.

No deficiencies or citations noted at today’s compliant investigation visit.

Exit interview conducted with ADM. A copy of this report was provided to ADM.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 4