435202608-7-19-2023-26-AS-RMAO-CU3L3A-20230725082334

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202608
Report Date: 07/19/2023
Date Signed: 07/19/2023 04:49:04 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/01/2020 and conducted by Evaluator Christine Dolores

COMPLAINT CONTROL NUMBER: 26-AS-20200501113134

FACILITY NAME:	DIYA SENIOR CARE CORPORATION		FACILITY NUMBER:	435202608
ADMINISTRATOR:	KAUR, BHUPINDER		FACILITY TYPE:	740
ADDRESS:	366 LASSENPARK CIR		TELEPHONE:	(408) 832-1153
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95136
CAPACITY:	6	CENSUS: 5	DATE:	07/19/2023
		UNANNOUNCED	TIME BEGAN:	03:20 PM
MET WITH:	Bhupinder Kaur		TIME COMPLETED:	04:55 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Licensee is not maintaining the facility grounds

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the findings of the above allegation. LPA met with Administrator, Bhupinder Kaur.

On 05/01/2020, the Department received the complaint. On 05/08/2020, the initial complaint investigation was conducted through a tele inspection visit because the Department had suspended on-site visits due to COVID-19.

On 05/08/2020, LPA Karen Taku interviewed a facility staff (S1). Based on the interview, S1 was aware of the disrepair and admits the facility’s fence is missing slats of wood.

SEE LIC9099-C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

Page: 1 of 5

Control Number 26-AS-20200501113134

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 07/19/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The photograph provided shows the facility’s fence is not in good repair. On 06/04/2020, the Administrator provided a follow-up photograph to the Department showing the fence repair.

The Department has investigated the above allegation and the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED. A deficiency was cited per California Code of Regulations, Title 22. See LIC9099-D.

This report was reviewed with the Administrator, Bhupinder Kaur and a copy of the report and appeal rights was provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 2 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/01/2020 and conducted by Evaluator Christine Dolores

COMPLAINT CONTROL NUMBER: 26-AS-20200501113134

FACILITY NAME:	DIYA SENIOR CARE CORPORATION		FACILITY NUMBER:	435202608
ADMINISTRATOR:	KAUR, BHUPINDER		FACILITY TYPE:	740
ADDRESS:	366 LASSENPARK CIR		TELEPHONE:	(408) 832-1153
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95136
CAPACITY:	6	CENSUS: 5	DATE:	07/19/2023
		UNANNOUNCED	TIME BEGAN:	03:20 PM
MET WITH:	Bhupinder Kaur		TIME COMPLETED:	04:55 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Night staff did not provide adequate supervision to meet the needs of a resident

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the finding of the above allegation. LPA met with Administrator, Bhupinder Kaur.

On 05/01/2020, the Department received the complaint alleging a resident who left the facility around 4:00AM without supervision.

On 05/08/2020, the initial complaint investigation was conducted through a tele inspection visit because the Department had suspended on-site visits due to COVID-19.

SEE LIC9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 26-AS-20200501113134

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 07/19/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The following documents were obtained to include R1 – R8’s physician’s report, appraisal needs and services plan, functional capabilities assessment, facility resident roster from January 2020 – February 2020, personnel report from January 2020 – March 2020, plan of operation, and police report records.

From 05/08/2020 – 06/11/2020, 3 out of 3 staff were interviewed. Based on interview, the facility has live-in staff on premises at-all-times and are not required to be awake throughout the night. Based on interview, the facility does not have door alarms installed but staff can hear when someone opens the door. Two Administrators stated the facility did not have a resident who fit the description provided by the reporting party.

The review of records shows the facility’s dementia plan of operation stating night staff will be required if any resident with dementia is determined to require an awake night supervision.

The review of additional records shows the police department responded to the facility on 2 occasions in March and May 2020. Both occasions were not regarding an alleged resident who left the facility around 4:00AM and who fit the description provided by the reporting party.

The Department has investigated the above allegation. Based on interview, record review, and observation the department has found the above allegation is unsubstantiated. An unsubstantiated finding indicates that although the allegation may have happened and/or is valid there is not a preponderance of evidence to show the alleged violations did or did not occur.

No deficiencies were cited per California Code of Regulations, Title 22.

This report was reviewed with Administrator, Bhupinder Kaur and a copy of the report was provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 26-AS-20200501113134

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 07/19/2023 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee has corrected the deficiency prior to visit by repairing the fence. POC Cleared.
	8 9 10 11 12 13 14	Based on observation, interview, and record review, the facility’s fence was in disrepair by missing slats of wood which poses a potential health, safety, and personal rights risks to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 5 of 5