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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202790
Report Date: 08/03/2021
Date Signed: 08/03/2021 02:35:49 PM

Document Has Been Signed on 08/03/2021 02:35 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:DELIA'S RESIDENTIAL COMMUNITY 1FACILITY NUMBER:
435202790
ADMINISTRATOR:BUNO, CARMENFACILITY TYPE:
740
ADDRESS:159 BLAKE AVETELEPHONE:
(669) 309-9724
CITY:SANTA CLARASTATE: CAZIP CODE:
95051
CAPACITY: 6CENSUS: 6DATE:
08/03/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Dina DomingoTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Joanne Roadilla conducted an unannounced case management visit today. LPA met with Administrators (ADM1) Dina Domingo and Carmen Buno (ADM2).

The purpose of the visit was to follow up on a report received by the Department. On 08/02/21, LPA received a call from ADM1 reporting that R1 while at the hospital, reported an incident of abuse by one of the staff at the facility.

At 10:40am, LPA interviewed ADM1 and ADM2, and reviewed and obtained copies of R1's records. Per ADM, alleged staff no longer works and has not been at the facility since April 2021.

At 11:40am, LPA interviewed R1.

No deficiencies cited during today's visit. Report was discussed with and a copy provided to Dina Domingo.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Joanne Roadilla
LICENSING EVALUATOR SIGNATURE: DATE: 08/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/03/2021
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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