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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202608
Report Date: 08/09/2024
Date Signed: 08/09/2024 05:02:15 PM


Document Has Been Signed on 08/09/2024 05:02 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:BHATIA, JASRAJFACILITY TYPE:
740
ADDRESS:366 LASSENPARK CIRTELEPHONE:
(408) 226-1162
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY:6CENSUS: 4DATE:
08/09/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:39 PM
MET WITH:Bani KaurTIME COMPLETED:
04:39 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced Case Management -other visit and met with Administrator Bani Kaur (ADM).

On 8/1/2024, around 9:30AM, resident R1 left the facility, and stating he/she is going out and will come back soon. R1 had a cell phone with him/her. R1 did not return to the facility after the curfew time. R1 came back to the facility on 8/2/2024, around 10:00AM by himself/herself.

CCL office received the incident report regarding R1 on 8/6/2024.

On 8/9/2024, LPA interviewed Administrator (ADM). ADM stated R1 is independently to leave the facility by self. ADM stated on 8/1/2024, R1 told the staff that he/she was going out and will be back soon. ADM stated R1 had cell phone with him/her at that time. ADM stated after the curfew time on 8/1/2024, staff found R1 still outside the facility. ADM stated staff called R1 several times but did not go through. ADM stated staff search around the neighborhood but were unable to find R1. ADM stated staff called police. ADM stated R1 returned to the facility on 8/2/2024 around 10:00AM by himself/herself. ADM stated R1 is fine after R1 returned to the facility.

LPA requested R1's physician report and appraisal/needs and service plan. Reviewed R1's physician report dated 5/6/2024, it specifies R1 "able to leave facility unassisted".

ADM stated the facility is updating R1's care plan. ADM stated she discussed with R1 and R1's case manager regarding the incident. ADM stated R1 agrees to return to the facility by 8:30PM every day, and he/she will call the facility in advanced if he/she cannot make it.

Exit interview was conducted with ADM. The 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: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2024
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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