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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202788
Report Date: 04/20/2023
Date Signed: 04/21/2023 09:25:40 AM

Document Has Been Signed on 04/21/2023 09:25 AM - 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: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: 4DATE:
04/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Administrator Carmen Buno,
Licensee Dina Domingo
TIME COMPLETED:
04:35 PM
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced annual inspection visit and met with Licensee (LIC) Dina Domingo and Administrator (ADM) Carmen Buno.

During visit, LPA toured the inside and outside of the facility. LPA toured the facility kitchen and observed at least 2 days of perishable food supply of at least 7 days of nonperishable food supply. Sharps and medications were locked in secured areas. There was a first aid kit in the facility. LPA observed additional food supply areas and secured areas for cleaning supplies and laundry detergents.

The facility bathroom had available soap, paper towels, and trash cans with lids. The showers had grab bars, non-skid mats, and shower chairs. The water temperature in the bathroom sinks ranged from 118.9F - 119.2F. The water temperature in the kitchen sink was 119.7F. Two fire extinguishers were observed and both were inspected on March 2023.

Facility smoke and carbon monoxide detectors were tested and found to be in functioning condition. Five out of five resident bedrooms had available bedding, drawers, and functioning lights. LPA reviewed facility records for staff and residents. LPA reviewed resident medications and central stored medication records.

Advisory Notes and Technical Violation were issued. See LIC9102 pages for more information.

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

This report was reviewed with Licensee Dina Domingo and Administrator Carmen Buno. A copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 04/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/20/2023
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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