435202788-7-2-2025-26-AS-KHOS-DJDLK8-20250708084907

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202788
Report Date: 07/02/2025
Date Signed: 07/02/2025 10:26:22 AM

Unsubstantiated

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
11/21/2024 and conducted by Evaluator Simranjit Rai

COMPLAINT CONTROL NUMBER: 26-AS-20241121142405

FACILITY NAME:	DELIA'S RESIDENTIAL COMMUNITY 2		FACILITY NUMBER:	435202788
ADMINISTRATOR:	BUNO, CARMEN		FACILITY TYPE:	740
ADDRESS:	167 BLAKE AVE		TELEPHONE:	(408) 799-6239
CITY:	SANTA CLARA	STATE: CA	ZIP CODE:	95051
CAPACITY:	6	CENSUS: 4	DATE:	07/02/2025
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Administrator, Dina Domingo.		TIME COMPLETED:	10:40 AM

ALLEGATION(S):

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Facility staff physically abused resident when resident requested for assistance.
Facility staff left resident's undergarments soaked in urine.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Simi Ran conducted an uannounced visit to conclude the complaint investigation of the allegations above. LPA met with Administrator, Dina Domingo and stated the purpose of today's visit.

On 11/21/2024, the Department received a complaint with the above allegations. On 11/27/2024, the Department coducted the initial 10-day compliant investigation visit.

Continuation on LIC 9099-C, Page 1 of 3.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025

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-20241121142405

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: DELIA'S RESIDENTIAL COMMUNITY 2	FACILITY NUMBER: 435202788
	VISIT DATE: 07/02/2025

NARRATIVE

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Page 2 of 3.
Facility staff physically abused resident when resident requested for assistance.

It was alleged that the facility staff physically abused the resident (R1) when R1 was requesting assistance.

On 11/20/2024, the Department interviewed 3 staff including ADM. Four out of the four staff stated resident R1 required assistance with ADLs, such as grooming and incontinence. Four out of four staff stated they have assisted R1 with ADLs and provided additional assistance when R1 requested. Four out of four staff stated they have not physically abused residents and they have not seen or heard staff physically abuse residents at the facility.

On 11/20/2024, the Department interviewed 4 residents. Four out of the four residents refused to speak with LPA and provide information during the investigation.

Based on review of R1’s Appraisal Needs and Services Plan dated and signed on 10/30/2024 by the Licensee and R1’s authorized representative, R1 is diagnosed Delirium and needs constant reminders and reality orientation. Facility staff’s plan is to provide constant reality orientation and reassurance and provide tools for reality orientation. R1 has agitation and anxiety with episodes of calling out constantly for no reason. Facility would reduce anxious mood and agitation and provide assurance by attending to needs timely. 1:1 social visit to promote a trusting relationship with staff.

Facility staff left resident's undergarments soaked in urine.

It was alleged the facility staff left resident's undergarments soaked in urine.

On 11/20/2024, the Department interviewed 3 staff including ADM. Three out of three staff stated they have not left resident’s undergarments soaked in urine. S1 stated she helped with assisting R1 in continence care and routinely checks on R1 and ensures R1's incontinent products are not soaked in urine.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20241121142405

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: DELIA'S RESIDENTIAL COMMUNITY 2	FACILITY NUMBER: 435202788
	VISIT DATE: 07/02/2025

NARRATIVE

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Page 3 of 3.

On 11/20/2024, the Department interviewed 4 residents. Four out of the four residents refused to speak with LPA and provide information during the investigation.

Based on review of R1’s Appraisal Needs and Services Plan dated and signed on 10/30/2024 by the Licensee and R1’s authorized representative, R1 is incontinent of bladder and bowel and needs assistance with transfers. R1 is able to turn in bed. The facility staff will assist and provide care in all areas needed.

Based on the interviews conducted with clients and staff and based on observation and records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Administrator and a copy of the report was provided.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 3