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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202788
Report Date: 03/29/2022
Date Signed: 03/29/2022 04:50:42 PM


Document Has Been Signed on 03/29/2022 04:50 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:DELIA'S RESIDENTIAL COMMUNITY 2FACILITY NUMBER:
435202788
ADMINISTRATOR:BUNO, CARMENFACILITY TYPE:
740
ADDRESS:167 BLAKE AVETELEPHONE:
(408) 799-6239
CITY:SANTA CLARASTATE: CAZIP CODE:
95051
CAPACITY:6CENSUS: 0DATE:
03/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:56 PM
MET WITH:Carmen BunoTIME COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) Carmen Buno. There are no staff and no residents in this facility now. This facility is next to Delia Residential Community #1, and next to Delia Residential Community #3. ADM stated the facility will hire more staff and will admit more residents later.

LPA toured the facility inside out with ADM. COVID posters were observed at main entrance and the facility. Screening station with masks, hand sanitizer, glove, thermometer and visitor log book was observed at the main entrance. ADM stated ADM will put more COVID posters on in facility. Living room, kitchen, dinning room and two restrooms were inspected. Five resident bedrooms, 1 office, and laundry area were inspected. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. PPE supplies were observed sufficient. ADM stated the facility stores the food supplies and PPE supplies for #1, #2, and #3 facilities. There are 3 bedrooms, one living room, one family room, and 2 restrooms at the second floor. The second floor is for ADM family use only. The facility has enough furniture to operate.

Fire extinguisher was serviced on 03/15/2022. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways.

No citation were noted today. Exit interview was conducted with ADM. This 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: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2022
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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