435202608-10-8-2024-26-AS-KHOS-DA5L3X-20241017082441

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202608
Report Date: 10/08/2024
Date Signed: 10/08/2024 04:49:58 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 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
01/24/2024 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20240124141044

FACILITY NAME:	DIYA SENIOR CARE CORPORATION		FACILITY NUMBER:	435202608
ADMINISTRATOR:	KAUR, BHUPINDER		FACILITY TYPE:	740
ADDRESS:	366 LASSENPARK CIR		TELEPHONE:	(408) 226-1162
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95136
CAPACITY:	6	CENSUS: 4	DATE:	10/08/2024
		UNANNOUNCED	TIME BEGAN:	01:39 PM
MET WITH:	Bani Kaur		TIME COMPLETED:	02:50 PM

ALLEGATION(S):

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Staff slapped resident with open hand.
Staff pushed resident causing fall injury.

INVESTIGATION FINDINGS:

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

On 1/24/2024, the Department received a complaint with the allegations that staff slapped residents with open hand and staff pushed resident causing fall injury.

On 2/1/2024, the Department conducted an initial investigation visit. LPA interviewed ADM, 3 staff and 6 residents.

LPA toured resident rooms and requested the roster of clients, LIC500, resident's physician report, appraisal Needs and Service plan.

Continue on LIC9099-C. Page 1 of 3.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024

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-20240124141044

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: DIYA SENIOR CARE CORPORATION	FACILITY NUMBER: 435202608
	VISIT DATE: 10/08/2024

NARRATIVE

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Staff slapped resident with open hand:
Staff pushed resident causing fall injury:
The allegations are that the facility staff slapped a resident's head with open hand, and the facility staff pushed the resident R1's door of the bedroom and hit the resident R1 causing fall injury.

On 2/1/2024, LPA interviewed resident R1. R1 stated on 11/20/2023 night, a staff opened his/her bedroom door without permission. R1 was at the back of the door and was hit. R1 stated he/she felt pain but did not fall down.

R1 stated on 12/14/2023, he/she was in the bedroom watching his/her tablet. R1 stated S1 came in the room and took the tablet. R1 stated he/she got it back and S1 slapped his/her head. R1 stated he/she did not get injuries.

LPA interviewed 5 residents. 1 out 5 residents just moved in the facility for 3 days and was unable to answer the questions. 3 out 5 residents stated they did not see any staff hit or slapped residents. 1 out 5 residents stated he/she heard residents R1 and staff S1 had altercations, but he/she did not see S1 hit or slapped R1.

LPA interviewed staff S1. S1 stated he/she is a night shift staff. S1 stated he/she needs to provide supervision to residents to make sure residents were sleeping in the rooms, and to make sure the head count is correct. S1 stated on 11/20/2023, he/she opened R1's bedroom door and the door hit R1. S1 stated it was not a hard hit and R1 did not fall down.

S1 stated on 12/14/2023, he/she entered R1's bedroom because R1 was making noise by watching movie on R1's tablet. S1 stated he/she took R1's tablet but R1 took it back immediately. S1 denied he/she slapped R1.

LPA interviewed 2 staff (S2, S3). Both stated they did not see S1 hit or slapped R1.

Continue on LIC9099-C. Page 2 of 3.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024

LIC9099 (FAS) - (06/04)

Page: 6 of 6

Control Number 26-AS-20240124141044

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: DIYA SENIOR CARE CORPORATION	FACILITY NUMBER: 435202608
	VISIT DATE: 10/08/2024

NARRATIVE

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LPA interviewed Administrator (ADM). ADM stated on 11/20/2023, staff S1 opened R1's bedroom and the door hit R1. ADM stated R1 did not fall down and did not get injury. ADM stated S1 is a night shift staff and needs to make sure residents were sleeping in the bedrooms. ADM stated after the incident, staff received the training that staff should open the door politely and don't enter the rooms if no permission or not necessary.

ADM stated on 12/14/2023, R1 made noise by watching movie on his/her tablet. ADM stated S1 took R1's tablet and R1 took it back immediately. ADM stated S1 denied he/she slapped on R1.

Based on review of Law Enforcement Task Report, it is unable to determine if the allegations did happen or not, and there are no sign of injury or abuse on R1.

Based on the interviews and record reviewed, there is no sign of injury or staff abused on R1 and it is unable to determine if the allegations did occur or did not occur.

Based on investigation, interviews conducted and records reviewed , 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 citations noted at today’s compliant investigation visit.

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

Page 3 of 3.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 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
01/24/2024 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20240124141044

FACILITY NAME:	DIYA SENIOR CARE CORPORATION		FACILITY NUMBER:	435202608
ADMINISTRATOR:	KAUR, BHUPINDER		FACILITY TYPE:	740
ADDRESS:	366 LASSENPARK CIR		TELEPHONE:	(408) 226-1162
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95136
CAPACITY:	6	CENSUS: 4	DATE:	10/08/2024
		UNANNOUNCED	TIME BEGAN:	01:39 PM
MET WITH:	Bani Kaur		TIME COMPLETED:	02:50 PM

ALLEGATION(S):

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Facility did not report incident to CCLD.
Facility staff confiscated resident's personal property.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation finding and met with Administrator (ADM) Bani Kaur.

On 1/24/2024, the Department received a complaint with the allegations that facility did not report incident to CCLD and facility staff confiscated resident's personal property.

On 2/1/2024, the Department conducted an initial investigation visit. LPA interviewed ADM, 3 staff and 6 residents.

LPA toured resident rooms and requested the roster of clients, LIC500, resident's physician report, appraisal Needs and Service plan.

Continue on LIC9099-C. Page 1 of 3.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024

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

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 26-AS-20240124141044

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: DIYA SENIOR CARE CORPORATION	FACILITY NUMBER: 435202608
	VISIT DATE: 10/08/2024

NARRATIVE

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Facility did not report incident to CCLD:
The allegation is that the facility did not report incident to CCLD.

On 2/1/2024, LPA interviewed Administrator (ADM). ADM stated for 11/20/2023 incident, he/she interviewed with other residents and other staff except R1 and S1. ADM stated no stated that they saw S1 hit R1. ADM stated it was an accident that a staff opened the door and hit resident R1 accidentally, and R1 was not injured.

ADM stated for 12/14/2023 incident, he/she did not receive any report about the incident. ADM stated no other staff and resident saw or heard the incident. ADM stated on 1/24/2024, police officers came to the facility to interview staff and residents, then he/she knew the incident. ADM stated on 1/25/2024, he/she sent the incident report to CCLD office.

LPA checked the incident reports sent to CCLD office, LPA found the incident report that the facility sent to CCLD office.

Based on interviews and record reviewed, no evidence to indicate the facility did not report incident to CCLD.

Facility staff confiscated resident's personal property:
The allegation is that facility staff confiscated resident tablet.

On 2/1/2024, LPA interviewed resident R1. R1 stated on 12/14/2023, staff S1 took his/her tablet but he/she took it back immediately. LPA interview staff S1. S1 stated on 12/14/2023, he/she took R1's tablet but R1 took it back immediately.

Based on the interviews, S1 did not confiscated R1's tablet.

Based on the interviews and documents reviewed, no evidence to indicate the facility is in financial distress.

Continue on LIC9099-C. Page 2 of 3.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 26-AS-20240124141044

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: DIYA SENIOR CARE CORPORATION	FACILITY NUMBER: 435202608
	VISIT DATE: 10/08/2024

NARRATIVE

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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.

Page 3 of 3.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 6