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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202599
Report Date: 08/09/2024
Date Signed: 08/09/2024 05:00:55 PM


Document Has Been Signed on 08/09/2024 05:00 PM - It Cannot Be Edited

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:
08/09/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Bani KaurTIME COMPLETED:
02:26 PM
NARRATIVE
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced Case Management -other visit and met with Administrator Bani Kaur (ADM).

LPA toured the facility inside and out. LPA observed 6 resident (R1 - R6) and 2 staff (S1, S2) in the facility.

LPA reviewed the 6 resident files, 2 out 6 residents are under age. Resident R1's admission date is 5/10/2024, and R2's admission date is 8/31/2022.

LPA received R1's under age exception request on 5/23/2024 at 2:35PM via an email from ADM.
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Based on the observation, interviews, and document review, the facility did not comply with the Title 22 Regulations. The facility has a census of 6 residents. 2 out of 6 residents are under the age of 60. ADM admitted 2 under age residents prior to get approval of the under age exception which is not compliance with the 25% limit under age residents allowed by the regulation in an RCFE facility.

R1's under age exception request letter was received on 5/23/2024 at 2:35PM via email, and R1 was admitted at the facility on on 5/10/2024.

This poses/posed a potential health, safety or personal rights risk to residents in care.

Deficiency noted today. See LIC809-D. Appeal rights was provided.

Exit interview was conducted with ADM. The reports were provided to ADM for signature. A copy of the reports was provided to ADM.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2024
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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Document Has Been Signed on 08/09/2024 05:00 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/16/2024
Section Cited
CCR
87455(b)(7)

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87455 Acceptance and Retention Limitations (b) The following persons may be accepted or retained in the facility: (7) Persons who are under 60 years of age whose needs are compatible with other residents in care, if they require the same amount of care and supervision as do the other residents in the facility.

This requirement is not met as evidenced by:
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ADM stated she read the title 22 section and understand it is important to be compliance with the regulations. ADM to submit a plan of correction by the POC due date.
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Based on the observation, interview, and document review, 3 out of 6 residents are under the age of 60. ADM did not get approval of the under age exception prior to admitting 2 under age residents which is not compliance with the 25% under age resident allowed by the regulation in an RCFE facility.
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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: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2024
LIC809 (FAS) - (06/04)
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