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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202608
Report Date: 07/19/2023
Date Signed: 07/19/2023 04:51:16 PM


Document Has Been Signed on 07/19/2023 04:51 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:KAUR, BHUPINDERFACILITY TYPE:
740
ADDRESS:366 LASSENPARK CIRTELEPHONE:
(408) 226-1162
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY:6CENSUS: DATE:
07/19/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Bhupinder KaurTIME COMPLETED:
04:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores arrived to the facility unannounced and met with Administrator (ADM), Bhupinder Kaur. A case management – deficiencies visit was conducted based on violations that were observed during a complaint investigation.

During the complaint investigation, LPA observed the facility does not maintain current records at the facility. LPA observed the resident’s physician’s report contained different facility addresses and the resident roster shows the incorrect facility name. On 07/19/23, ADM states she has a DBA of "Diya Senior Care Home" which is why she uses that name on the facility's records. LPA informed ADM that the facility records should be maintained and correct per the License of the facility. ADM stated understanding.

During the complaint investigation, it was also found on 03/15/2020 a resident (R1) eloped from the facility. ADM filed a missing person report, called hospitals, and found R1 was at the Santa Clara Valley Medical Center. R1 returned to the facility on the same day. Based on record review, on 05/12/2020, a case management visit was conducted by LPA Joanne Roadilla in which the case management was pending due to additional reports.

Based on the requested reports, R1 was diagnosed with a severe neurocognitive impairment and was unable to leave the facility unassisted. The review of records show, R1’s needs and services plan was not updated to reflect a plan to address R1’s behavior of elopement.

A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D. Advisory note provided. This report was reviewed with Administrator, Bhupinder Kaur and a copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2023
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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Document Has Been Signed on 07/19/2023 04:51 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 CORPORATION
FACILITY NUMBER: 435202608

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/26/2023
Section Cited
CCR
87463(a)

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(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: This requirement is not met as evidenced by:
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Licensee stated to ensure to update the appraisal/needs and services plan annually and upon change of condition. Licensee will submit a plan in writing to ensure compliance of Section 87463 to LPA Dolores via email by POC due date 07/26/2023
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Based on record review and interview, the licensee did not ensure to update the resident’s appraisal/needs and services plan to reflect a plan to address R1’s behavior of elopement which poses a potential health, safety, and personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2023
LIC809 (FAS) - (06/04)
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