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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202608
Report Date: 07/14/2023
Date Signed: 07/14/2023 01:47:52 PM


Document Has Been Signed on 07/14/2023 01:47 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: 6DATE:
07/14/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:02 PM
MET WITH:Bani KaurTIME COMPLETED:
01:20 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced Case Management-Incident visit and met with Administrator (ADM) Bani Kaur.

Today's Case Management-Incident visit continued 10/26/2022 Case Management-Incident investigation visit.

On 10/18/2022, the Department received an incident report regarding a resident (R1) who fell and died in the bedroom on 10/18/2022. 911 was immediately called when staff found R1 in bedroom floor.

On 10/26/2022, the Department interviewed 4 residents (R2-R5), 2 staff (S1-S2), and ADM. R1's physician report, Appraisal Needs and Service Plan, medical records were obtained and reviewed.

Based on the review of medical records of R1’s cause of death, R1’s cause of death is due to heart disease and other underlying medical health issues.

Exit interview was conducted with ADM. The report was provided to ADM for signature. A copy of the report was provided to ADM.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2023
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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