435202599-12-12-2022-26-AS-KHOS-CMKQNV-20221229111946

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202599
Report Date: 12/12/2022
Date Signed: 12/12/2022 04:29:02 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
12/06/2021 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20211206154910

FACILITY NAME:	DIYA SENIOR CARE HOME		FACILITY NUMBER:	435202599
ADMINISTRATOR:	KAUR, BHUPINDER		FACILITY TYPE:	740
ADDRESS:	276 CLEARPARK CIRCLE		TELEPHONE:	(408) 629-0388
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95136
CAPACITY:	6	CENSUS: 5	DATE:	12/12/2022
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Bani Kaur		TIME COMPLETED:	01:50 PM

ALLEGATION(S):

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Resident had access to hazardous object.
Staff is not providing a comfortable environment for resident.
Staff did not prevent inappropriate interactions between residents.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced complaint Investigation visit to deliver the investigation findings, and met with administrator(ADM) Bani Kaur.

On 12/06/2021, the Department received a complaint with the above allegations.

On 12/10/2021, LPA Steve Chang conducted an initial 10 day inspection/investigation, and met with ADM. LPA interviewed ADM, 1 staff (S1) and 5 residents (R1 - R5). LPA requested resident's Physician’s Report, Appraisal/Needs and Service Plan and incident reports. LPA toured the facility with ADM.

Continued on 9099-C. Page 1 of 3.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2022

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 3

Control Number 26-AS-20211206154910

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 HOME	FACILITY NUMBER: 435202599
	VISIT DATE: 12/12/2022

NARRATIVE

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Resident had access to hazardous object:

On 12/10/2021, LPA reviewed the documents, an incident happened on 10/20/2021, a suspect resident (SR1), acted aggressively, and yelled to other resident. 911 was called by the facility, and SR1 was sent to Emergency Psychiatric Service (EMS) immediately. No one was hurt.

On 12/10/2021 and 08/04/2022, LPA interviewed Administrator (ADM) and staff S1, both of them stated the residents could not access the knives. They stated knives were locked by the facility, and no resident had the key. They stated they never saw any resident accessed the knives in the facility.

On 12/10/2021, LPA interviewed 5 residents (R1 - R5). None of them stated they could access the facility knives, and none of them stated they saw other residents accessed the knives.

On the same days, LPA toured the facility inside out, and observed the facility knives were locked.

On 9/21/2022, LPA interviewed 5 residents (R1 - R5). 5 Out of 5 stated they never saw any resident held the knife and threatened other residents. 5 Out of 5 stated they could not access the knives in the facility. On the same day, LPA interviewed ADM. ADM stated only the staff have the keys to access the knives in the facility.

On 11/1/2022, LPA interviewed R1 and R2. They stated SR1 acted aggressively in the incident, but they did not see SR1 held the knives.

Based on the investigation, observation, and interviews conducted, the facility knives were observed locked, all the residents stated they could not access the knives. All the residents stated they did not observe any resident held the knives. ADM and S1 stated no residents could access the knives.

Continued on 9099-C. Page 2 of 3.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20211206154910

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 HOME	FACILITY NUMBER: 435202599
	VISIT DATE: 12/12/2022

NARRATIVE

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Staff is not providing a comfortable environment for resident:
Staff did not prevent inappropriate interactions between residents:

On 12/10/2021 and 08/04/2022, LPA interviewed ADM and S1. Both them stated only resident SA1 had the aggressive behavior. ADM and S1 stated all other residents have no any history of aggressive behavior. ADM stated SA1 moved out from the facility on 10/21/2021. ADM stated the facility has the house rules to regulate residents' behaviors. ADM and S1 stated if the facility staff find the resident has the inappropriate or aggressive behavior, the staff will separate the aggressive resident from other residents immediately to protect other residents, and will redirect and to stabilize him/her.

On 12/10/2021 and 9/21/2022, LPA interviewed 5 residents (R1 - R5). None of them stated they felt unsafe in the facility. All of them stated they never saw any resident held the knife and threatened other residents. All of them stated only SR1 had the aggressive behavior, and SR1 already moved out on 10/21/2021. None of them stated they were hit by other residents or hit by staff. All of them stated they never saw the altercations between residents.

ADM provided LPA the email logs with social workers and psychiatric agency that ADM claimed that the facility tried the best to provide help to stabilize SA1. ADM stated the facility could not confirm that SA1 was stable, so the facility did not let SA1 came back to the facility. ADM stated the facility tried the best to provide a comfortable environment for resident.

Based on the records reviewed and interviews conducted, the facility provided the supervision of care to residents. The facility took action on the resident's aggressive behavior. The facility tried the best to protect the residents.

Based on investigation, observations, and interviews conducted, the Department found that the above allegation is UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.

No citations noted at today’s complaint investigation visit. Exit interview was conducted with ADM. This report was provided to ADM.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2022

LIC9099 (FAS) - (06/04)

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