435202608-6-26-2020-26-AS-RMAO-BRELUH-20200711090359

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202608
Report Date: 06/26/2020
Date Signed: 06/26/2020 03:54:28 PM

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
10/15/2019 and conducted by Evaluator James G Santos

COMPLAINT CONTROL NUMBER: 26-AS-20191015145025

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:	06/26/2020
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Bani Kaur		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff failed to transport residents to appointments
Staff threatens residents
Illegal eviction
Staff failed to provide residents with privacy
Staff restrict residents from using facility phone

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) James Santos conducted an unannounced tele-visit today to deliver the investigation finding on the above allegations. Due to the current COVID-19 situation, LPA met with administrator, Bani via tele-conference.

On 10/25/2019, LPA conducted the initial investigation. During initial visit, LPA interviewed staff (S1 and S2) and resident (R1) and made observations. Administrator arrived shortly thereafter and LPA discussed the to the administrator the purpose of the visit. Subsequent visit was made on 1/15/2020 and conducted additional interviews with administrator, staff (S1 and S2) and residents (R2 to R7). LPA also made observations.

Subsequent visit was made on 2/5/2020. During this visit,LPA inspected the home's food supply.

Continued on page 2

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: George Nwafor	TELEPHONE: (650) 269-7419
LICENSING EVALUATOR NAME: James G Santos	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2020

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 6

Control Number 26-AS-20191015145025

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: 06/26/2020

NARRATIVE

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Staff failed to transport residents to appointments

Between 10/25/2019 to 1/15/2020, LPA conducted visits to interview the administrator, 2 staff members (S1 and S2) and 6 residents (R1 to R6). Administrator, staff members and residents stated that residents are taken to their scheduled medical appointments.

Based on the residents’ appointment documentation for 8/01/2019-10/28/2019 obtained from the facility, it shows that residents were transported to their appointments as scheduled as agreed with their admission agreement where it states that the facility or outside vendor will provide transportation to medical and dental appointments.

Staff threatens residents

Between 10/25/2019 to 1/15/2020, LPA conducted visits to interview the administrator, 2 staff members (S1 and S2) and 7 residents (R1 to R7). Staff members including the administrator denied threatening residents, and residents denied being threatened by staff to cut food and other basic services.

Illegal eviction

On 1/15/2020, LPA conducted interviews with the administrator and S1. Administrator stated that a 30-day eviction notice was provided to R1 and R1’s Case Manager. LPA obtained a copy of R1’s eviction letter dated 9/26/2019. R1 was given an eviction notice due to repeated aggressive behaviors which poses a risk to health and safety to the other residents and staff.

Based on the interviews, administrator denied allegation that R1 was illegally evicted. S1 stated they had a resident (R1) that was issued an eviction due to not following house rules.

Continued on page 3.

SUPERVISOR'S NAME: George Nwafor	TELEPHONE: (650) 269-7419
LICENSING EVALUATOR NAME: James G Santos	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 26-AS-20191015145025

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: 06/26/2020

NARRATIVE

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LPA reviewed facility’s progress notes of R1 for the period of Sept 2018 to November 2019 which shows documentation of R1’s behaviors such as agitation, verbal aggression, being disrespectful to other residents and staff, calling 911 multiple times for non-emergency issues. Administrator stated that the agreed plan of actions for R1 did not work and staff was not able to redirect R1 as R1 did not listen.

On 6/11/2020 LPA interviewed R1’s Case Manager on the phone. Case Manager stated that they were aware of R1’s behaviors and had a discussion with the administrator regarding the eviction and relocation of the resident.

Staff failed to provide residents with privacy

Between 10/25/2019 to 1/15/2020, LPA conducted visits to interview the Administrator, 2 staff member (S1 and S2), and 7 residents (R1 to R7), Both Administrator and two staff members stated that privacy is given during visitation. R1 - R6 all stated no one visits them in the home. Per interview with R7, R7's mom visits the home and they talk in the room for privacy.

Program design submitted to CCLD indicated that the facility has designated areas such as the living room, outside patio areas and individuals’ bedroom where visitors can have private conversations with the residents.

Staff restrict residents from using facility phone

Between 10/25/2019 to 1/15/2020 LPA conducted visits to interview the Administrator, 2 staff members (S1 and S2) and 7 residents (R1 to R7). Administrator, staff members and residents stated residents are able to use the facility telephone and the telephone is working. Admission agreement also indicated that residents have access to make phone calls at the facility limited to 5 minutes.

During visit on 1/15/2020, LPA checked the phone in the home and it was connected.

Continued on page 4.

SUPERVISOR'S NAME: George Nwafor	TELEPHONE: (650) 269-7419
LICENSING EVALUATOR NAME: James G Santos	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2020

LIC9099 (FAS) - (06/04)

Page: 3 of 6

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
10/15/2019 and conducted by Evaluator James G Santos

COMPLAINT CONTROL NUMBER: 26-AS-20191015145025

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:	06/26/2020
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Bani Kaur		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff failed to provide residents with nutritious meals

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) James Santos conducted an unannounced tele-visit today to deliver the investigation finding on the above allegation. Due to the current COVID-19 situation, LPA met with administrator, Bani Kaur via tele-conference.

On 10/25/2019, LPA conducted the initial investigation. Subsequent visits were made on 1/15/2020 and 2/5/2020 to conduct interviews with staff, residents, and observations.

Between 10/25/2019 to 1/15/2020 LPA conducted visits to interview the administrator, 2 staff (S1 and S2) and 7 residents (R1-R7). Administrator, staff, and residents stated that the facility provides 3 meals a day and snacks and different variery of food.

During interview with S2, who is also the cook at the facility, S2 denied serving hot dogs 7 days a week at the facility. S2 stated they try to follow their menu but it varies at times.

Continued on page 2.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: George Nwafor	TELEPHONE: (650) 269-7419
LICENSING EVALUATOR NAME: James G Santos	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2020

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

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 26-AS-20191015145025

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: 06/26/2020

NARRATIVE

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Observations of food supply were conducted between 10/25/2019 to 2/5/2020. Food served in the facility are consist of meat, milk, vegetables, bread, beverage drink, fruits and waffles.

Food menu reviewed listed different meal options for breakfast, lunch, and dinner. Hot dog was listed on the menu.

The department has investigated this complaint in regards with the above allegation.

Based on the interviews with staff and residents, observation and review of record, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the above allegation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

No deficiencies cited. This report was reviewed with administrator and a copy of this report was emailed on 6/26/20 to the administrator for signature.

SUPERVISOR'S NAME: George Nwafor	TELEPHONE: (650) 269-7419
LICENSING EVALUATOR NAME: James G Santos	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2020

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 26-AS-20191015145025

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: 06/26/2020

NARRATIVE

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The Department has investigated the above allegations. Based on the interviews conducted with residents and staff, observations and documents reviewed, the allegations were UNFOUNDED. Meaning that the allegations were false, could not have happened and/or are without reasonable basis.

No deficiencies cited. This report was reviewed with administrator and a copy of this report was emailed on 6/26/20 to the administrator for signature.

SUPERVISOR'S NAME: George Nwafor	TELEPHONE: (650) 269-7419
LICENSING EVALUATOR NAME: James G Santos	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2020

LIC9099 (FAS) - (06/04)

Page: 6 of 6