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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202608
Report Date: 11/21/2024
Date Signed: 11/21/2024 04:44:38 PM

Document Has Been Signed on 11/21/2024 04:44 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:DIYA SENIOR CARE CORPORATIONFACILITY NUMBER:
435202608
ADMINISTRATOR/
DIRECTOR:
BHATIA, JASRAJFACILITY TYPE:
740
ADDRESS:366 LASSENPARK CIRTELEPHONE:
(408) 226-1162
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
11/21/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:Bani KaurTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced Case Management - other visit and met with Administrator Bani Kaur (ADM).

The purpose of today's visit is to collect more information regarding the 30 days eviction letter that the facility issued to resident R1.

On 11/15/2024, the Department received a notice from Administrator Bani Kaur (ADM) that the facility issued a 30 day eviction letter to resident R1 due to the facility is unable to provide the level of care to R1.

On 11/11/2024, the facility issued a 30 day eviction letter to R1. The reasons of the eviction are resident R1 violated the Admission Agreement and the house rule.

LPA toured the resident rooms. LPA interviewed ADM, 2 staff (S1, S2), and 3 residents (R1, R2, R3).

LPA request resident's ID form, pre assessment form, physician report, appraisal needs and service plan, incident reports, functional capability form, and progress notes.

Exit interview was conducted with ADM. The report was provided to ADM to review. A copy of the report was provided to ADM.
Romeo ManzanoTELEPHONE: (408) 277-1289
Chihhsien ChangTELEPHONE: (408) 904-9843
DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2024
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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