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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202789
Report Date: 04/07/2026
Date Signed: 04/07/2026 02:48:37 PM

Document Has Been Signed on 04/07/2026 02:48 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:DELIA'S RESIDENTIAL COMMUNITY 3FACILITY NUMBER:
435202789
ADMINISTRATOR/
DIRECTOR:		DOMINGO, DINAFACILITY TYPE:
740
ADDRESS:175 BLAKE AVETELEPHONE:
(408) 799-6239
CITY:SANTA CLARASTATE: CAZIP CODE:
95051
CAPACITY: 6CENSUS: 4DATE:
04/07/2026
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Administrator, Carmen BunoTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced case management for annual continuation from 3/26/2026. LPA Rai met with Administrator, Carmen Buno and stated the purpose of today's visit.

LPA Rai reviewed at random 2 staff files and 2 resident files. 2 Out of 2 staff files were complete. 2 Out of 2 resident files were complete.

LPA Rai reviewed at random 2 medications and medication records. LPA Rai observed resident R1's 2 out of 8 medications did not have start date on the Centrally Stored Medication Log. LPA Rai observed R1's 1 out of 8 medications (MED1) which were centrally stored not recorded on the Centrally Stored Medication Log. LPA Rai and facility staff S1 counted the tablets remaining in MED1 were 39 tablets when the initial tablets in the medication when filled was 100 tablets. S1 stated the facility staff are administering MED1 to resident R1 1 tablet daily. LPA Rai observed 2 out of 8 medications (MED2 & MED3) did not have start dates written on the Centrally Stored Medication Log. LPA Rai and S1 counted tablets remaining in MED2 bottle which was 46 tablets, when originally it was filled with 100 tablets. LPA Rai and S2 counted tablets remaining in MED3 bottle which was 26 tablets, when originally it was filled with 90 tablets. S1 stated the facility staff are administering MED2 and MED3 to resident R2 1 tablet daily.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Continuation on LIC 809-C, Page 1 of 2.
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Simranjit Rai
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/07/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 04/07/2026 02:48 PM - It Cannot Be Edited


Created By: Simranjit Rai On 04/07/2026 at 11:59 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: DELIA'S RESIDENTIAL COMMUNITY 3
FACILITY NUMBER: 435202789

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/14/2026
Section Cited
CCR
87465(h)(6)

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87465 Incidental Medical and Dental Care (h) (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year...
This requirement is not met as evidenced by:
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Administrator stated to submit a written plan of action understanding regulation and will ensure R1's centrally stored prescription medication are recorded on the Centrally Stored Medication log by POC due date. Administrator agreed and understood.
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Based on interview and record review, resident R1's 1 out of 8 medications was not logged on the Centrally Stored Medication Log which poses/posed a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:
Simranjit Rai
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2026


LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 3
FACILITY NUMBER: 435202789
VISIT DATE: 04/07/2026
NARRATIVE
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Page 2 of 2.

Deficiencies were cited per California Code of Regulations, Title 22, please see LIC 809-D. This report was reviewed with Administrator, Carmen Buno and a copy of the report was provided. LIC 858 and LIC 859 were provided. Appeal Rights was provided.
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Simranjit Rai
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2026
LIC809 (FAS) - (06/04)
Page: 4 of 4