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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202608
Report Date: 09/21/2022
Date Signed: 09/21/2022 04:54:54 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/21/2022 04:54 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
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: 4DATE:
09/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Bani KaurTIME COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) Bani Kaur. Upon arrival, ADM took LPA body temperature, asked the infection control questionnaires, and checked LPA in the visitor log book.

LPA toured the facility inside out with ADM. COVID posters were observed at main entrance and the facility. Screening station with masks, hand sanitizer, thermometer and visitor log book was observed at the main entrance. Living room, kitchen, dinning room and two restrooms were inspected. Trash cans with cover and trash can without cover were observed in restrooms. ADM removed the trash cans without covers in the restrooms. Paper towels were observed with holders. One of the restrooms did not have the posters of washing hands for 20 seconds. ADM put the posters of washing hands for 20 seconds in the restroom before LPA wrote the report. 3 shared resident bedrooms, and laundry room were inspected. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Medication closet, knives closet, and cleaning product closet were observed locked. Room temperature was at 72 degree F, and hot water temperature was at 110 degree F in facility.

Fire extinguisher was serviced on 09/08/2022. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways.

ADM stated all the residents and staff are fully vaccinated and done with booster. ADM stated the facility already submitted the Infection Control Plan to CCL Office. No citation were noted today. Exit interview was conducted with ADM. This report was provided to ADM for signature.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2022
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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