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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202608
Report Date: 10/26/2022
Date Signed: 10/26/2022 12:47:39 PM


Document Has Been Signed on 10/26/2022 12:47 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:
10/26/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:11 AM
MET WITH:Bani KaurTIME COMPLETED:
11:59 AM
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Licensing Program Analyst (LPA) conducted an unannounced case management - incident investigation visit today, and met with Administrator (ADM) Bani Kaur. Two staff (S1, S2), 4 residents (R1 - R4), and ADM were interviewed.

The following document were obtained including staff schedule, resident admission agreement, resident physician report, Appraisal Needs and Service Plan, medication list record, Rosters of staff and residents, and the contact information of conservator and case manager.

The Department needs more investigation for this incident.

Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of this was provided to ADM
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2022
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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