435202608-6-19-2020-26-AS-RMAO-BQVLHW-20200624084658

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202608
Report Date: 06/19/2020
Date Signed: 06/19/2020 10:20:24 AM

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
03/24/2020 and conducted by Evaluator Joanne Roadilla

COMPLAINT CONTROL NUMBER: 26-AS-20200324160540

FACILITY NAME:	DIYA SENIOR CARE CORPORATION		FACILITY NUMBER:	435202608
ADMINISTRATOR:	KAUR, BHUPINDER		FACILITY TYPE:	740
ADDRESS:	366 LASSENPARK CIR		TELEPHONE:	(408) 832-1153
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95136
CAPACITY:	6	CENSUS: 5	DATE:	06/19/2020
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Bhupinder Kaur		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Client records not available to facility staff.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Joanne Roadilla conducted an unannounced complaint tele-visit today to deliver investigation findings. The Department has suspended on site visits due to COVID-19 shelter in place order by Governor Newsom. LPA spoke to Administrator (ADM) Bani Kaur.

On 4/3/20, LPA Natkarn Shugan conducted an initial complaint tele-visit inspection/investigation of the above allegation that on 3/23/20, 911 was called and when the first responders arrived, the facility did not have records on resident (R1). Allegation also stated that the facility was unable to provide R1’s family information or medical history and that the first responder had to estimate R1’s age.

During LPA Shugan’s interview, ADM stated that R1’s Social Security card and medical list are always available. ADM also stated that resident’s personal information and emergency information are kept at the home.

Continued on 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Joanne Roadilla	TELEPHONE: (408) 205-2348
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2020

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

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20200324160540

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 CORPORATION	FACILITY NUMBER: 435202608
	VISIT DATE: 06/19/2020

NARRATIVE

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On 4/20/20, LPA Roadilla conducted a subsequent complaint tele-visit inspection/investigation to interview ADM and staff (S1 and S2) and to review resident files and medical records.

During LPA Roadilla’s inspection, resident files were observed to be located on top of one of the pantry shelves. ADM stated that R1’s files are kept in another facility since R1 is no longer residing there.

Two out of two (2 out of 2) staff who were interviewed stated resident’s files and medical records are in the pantry and they have access to them when necessary. Two out of two (2 out of 2) staff who were interviewed also stated that in case of an emergency, the protocol is to call 911 then prepare resident’s medical records to provide to the first responders when they arrive.

During the interview, LPA learned from S1 that they made another 911 call for R1 on 3/27/20. S1 stated that on both occasions, R1’s medical record was provided to the first responders. According to S1, there were first responders from the Fire Department and there were also first responders from the ambulance. S1 stated that when asked by one of the first responders what is R1’s age, S1 could only provide an estimate. S1 also stated that one of the first responders from the Fire Department brought R1’s medical records with them when they transported R1 to the hospital. Afterwards, S1 asked ADM to provide another copy of R1's records to put in the residents file folder.

The Department has completed the investigation of this complaint allegation. Based on interviews conducted and gathered information, the Department has 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 allegation did or did not occur.

No deficiencies cited during today's tele-visit. Report was discussed with and a copy sent to Bani Kaur to sign and mail back to CCL.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Joanne Roadilla	TELEPHONE: (408) 205-2348
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2020

LIC9099 (FAS) - (06/04)

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