435202788-7-2-2025-26-AS-KHOS-DJDLSY-20250708090130

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202788
Report Date: 07/02/2025
Date Signed: 07/02/2025 10:24:48 AM

Unfounded

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
03/11/2025 and conducted by Evaluator Simranjit Rai

COMPLAINT CONTROL NUMBER: 26-AS-20250311101753

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:	09:00 AM
MET WITH:	Administrator, Dina Domingo		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Facility staff did not administer resident's medication as prescribed by physician.
Facility staff installed a security camera in resident's room without resident's consent.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with the Administrator Dina Domingo and stated the purpose of today’s visit.

On 3/11/2025, the Department received a complaint with the above allegations. On 3/19/2025, the Department conducted an initial investigation at the facility.

Continuation on LIC 9099-C, Page 1 of 2.

Unfounded

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 5

Control Number 26-AS-20250311101753

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 2.
Facility staff did not administer resident's medication as prescribed by physician.
It was alleged that resident R1 was not being administered Medication #1 as prescribed by physician.

On 3/19/2025, the Department interviewed 2 staff (S1-S2). S2 stated R1 did not have physician’s order for facility to administer Medication #1, which was not a routine medication but as need (PRN) medication. S2 stated the Hospice RN was able to administer the medication but they only had orders signed by a nurse and not a physician. S2 stated Hospice agency was aware of this and they would administer the medication #1 as it was a PRN medication.
On 3/19/2025, the Department interviewed 2 residents (R1-R2). Two out of two residents were not able to answer the questions requested at the time of the visit.
On 3/19/2025, the Department interviewed 1 witness (W1). W1 stated that they did not see or hear any issues with facility staff not administering medications to the residents.

Based on review of resident R1’s file, R1’s Hospice medication orders for Medication #1 was signed by a nurse and not a physician. Based on review of R1’s hospice visit log, R1’s nurse stated medication #1 order, but order was signed by nurse and not physician.

Facility staff installed a security camera in resident's room without resident's consent.

On 3/19/2025, the Department interviewed 2 staff (S1-S2). Two out of two staff stated resident’s responsible party was aware of security camera and signed consent forms to have camera in resident’s room.
On 3/19/2025, the Department interviewed 2 residents (R1-R2). Two out of two residents were not able to answer the questions requested at the time of the visit.
Based on review of resident R1’s Admission Agreement, page 35 out of 36, R1’s responsible party signed to have non-recording video monitors in the resident’s living space.

The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.
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: 2 of 5

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
03/11/2025 and conducted by Evaluator Simranjit Rai

COMPLAINT CONTROL NUMBER: 26-AS-20250311101753

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:	09:00 AM
MET WITH:	Administrator, Dina Domingo		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Facility staff is not meeting resident's needs due to lack of staffing.
Facility staff did not follow resident's care plan.

INVESTIGATION FINDINGS:

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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: 3 of 5

Control Number 26-AS-20250311101753

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 is not meeting resident's needs due to lack of staffing.

On 3/19/2025, the Department interviewed 2 staff (S1-S2). Two out of two staff stated there was enough staffing to meet the resident’s needs. S1 stated there were two residents and 1 staff assisting both resident. S1 stated there were available staff from the next facility, which also belongs to the Licensee, and they can always come to assist residents in an emergency. S2 stated there are enough staff to meet the resident’s needs. S2 stated they will help assist S1 when there were only 2 residents at the facility to cover breaks and assist with other duties at the facility.
On 3/19/2025, the Department interviewed 2 residents (R1-R2). Two out of two residents were not able to answer the questions requested at the time of the visit.
On 3/19/2025, the Department interviewed 1 witness (W1). W1 stated they did not hear or see any issues with the facility staff not meeting the resident’s needs at the facility. W1 stated the staff are always available when requested.

Based on review of staff schedule from January 2025 to March 2025, there are 1 to 2 staff assigned throughout the day, along with 1 administrator on shift throughout the day.

Facility staff did not follow resident's care plan.
It was alleged that the resident wasn’t having a consistent sleep pattern, where the staff did not ensure the resident was sleeping in the night and awake in the day.

On 3/19/2025, the Department interviewed 2 staff (S1-S2). Two out of two staff stated the R1 had a hard time adjusting to the new facility and was restless at night. S2 stated the night shift staff would do safety checks at night with the other residents and stay in R1’s room to ensure R1 was comfortable to sleep. S2 stated R1’s hospice team had initiated medication which they was administer when facility staff would report R1 being restless at night.
On 3/19/2025, the Department interviewed 2 residents (R1-R2). Two out of two residents were not able to answer the questions requested at the time of the visit.

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: 4 of 5

Control Number 26-AS-20250311101753

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 3/19/2025, the Department interviewed 1 witness (W1). W1 stated they have not seen or heard facility staff not following resident’s care plan. W1 stated they are present in the facility in the day time and have not observed facility staff’s night time activities. W1 stated when they are present in the facility, the residents are awake and doing activities

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: 5 of 5