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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202608
Report Date: 10/25/2021
Date Signed: 10/25/2021 04:43:50 PM

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 CORPORATIONFACILITY NUMBER:
435202608
ADMINISTRATOR:KAUR, BHUPINDERFACILITY TYPE:
740
ADDRESS:366 LASSENPARK CIRTELEPHONE:
(408) 226-1162
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY:6CENSUS: 5DATE:
10/25/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Bhupinder Kaur, ADMTIME COMPLETED:
11:59 AM
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At 10:45AM, licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection, and met with administrator (ADM) Bhupinder Kaur.

Upon Arrival, facility staff Victor Esteban (VE) took LPA's body temperature, and checked LPA in the visitor log book. LPA observed the COVID posters in the facility.

There are one staff live-in room, 3 resident shared rooms, and three restrooms in the facility. LPA observed one empty bedroom and one storage room in the second floor. Not all the trash cans were with covers, ADM stated facility will fix it in two weeks. LPA did not see paper towel in the kitchen, ADM put the paper towel with holder in kitchen immediately. Medication closet was observed locked. Knife closet was observed locked. Cleaning products and detergents were locked in the garage. LPA checked PPE supplies, PPE supplies were observed sufficient. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Beds in the resident shared rooms were observed 6 feet apart. 2 staff and 5 residents were observed in the facility.

LPA toured the backyard with ADM. Mattress and some garbage were observed, ADM stated the facility already scheduled 11/02/2021 to remove that.

LPA discussed LIC808 with ADM. ADM stated all the staff and residents are fully vaccinated. ADM stated all the residents and staff already finished the booster shots.

No deficiency or allegation was issued today. Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of this report was emailed to ADM.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2021
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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