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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202790
Report Date: 09/13/2021
Date Signed: 09/14/2021 08:53:40 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
04/02/2021 and conducted by Evaluator Joanne Roadilla
COMPLAINT CONTROL NUMBER: 26-AS-20210402135914
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: 5DATE:
09/13/2021
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Carmen BunoTIME COMPLETED:
06:15 PM
ALLEGATION(S):
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Resident has had extreme weight loss.
Resident's weight loss not brought to the attention of the resident's responsible person.
Food service is inadequate.
Resident's underpants are too big.
The yard is cluttered with debris.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Joanne Roadilla conducted an unannounced Complaint Investigation to deliver the investigation findings on the above allegations. LPA met with Administrator Carmen Buno and discussed the purpose of the visit.

On 04/02/21, the department received a complaint with the above allegations. On 04/12/21, LPA conducted an initial 10-day investigation tele-visit. LPA interviewed 5 staff (S1-S5) and requested for residents’ records.

Continued on LIC9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Joanne Roadilla
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021
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 7
Control Number 26-AS-20210402135914
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 1
FACILITY NUMBER: 435202790
VISIT DATE: 09/13/2021
NARRATIVE
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Resident has had extreme weight loss

Based on staff interviews, 5 out of 5 staff stated that R1 refuses to eat because R1 thinks the food is being poisoned and that the water is plastic. Staff (S1) stated that R1’s MD was notified that R1 is refusing everything including medication.

Based on records review, facility informed MD of R1’s refusal to take medication. Facility also reported to MD that R1 stays in bed most of the time, has poor appetite and was choosy with food.

S1 stated that per R1’s physician’s (MD) order, R1’s medication is mixed with the food but R1 could taste the medicine in the food and would refuse to eat it. S1 stated that they normally offer R1 the same food as the other residents, sometimes R1 would eat it and sometimes R1 would ask for something else. They would make it for R1 but then R1 would change mind again and ask for something else. R1 would check if they would make it but R1 still wouldn’t eat it. R1 would throw the food on the ground or at the staff.

Resident's weight loss not brought to the attention of the resident's responsible person

Based on staff (S1) interview, when R1 was admitted at the facility in April 2019, R1 weighed around 240lbs. R1’s spouse was made aware of R1’s condition by the facility and R1’s spouse would visit R1 every weekend until around December 2020 wherein R1 weighs around 150lbs. When COVID-19 happened, R1’s spouse would still visit by R1’s window until R1’s spouse could no longer visit due to a medical condition. S1 stated that R1’s family members (FM) became R1’s conservator since May 2020 but they were not told until the later part of the year.

Based on staff (S2) interview, FM is consistently notified about R1's condition, R1's behavior, and R1's refusal to take medications, R1 refusing care and R1 not eating and losing weight.

Continued LIC9099-C.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Joanne Roadilla
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 26-AS-20210402135914
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 1
FACILITY NUMBER: 435202790
VISIT DATE: 09/13/2021
NARRATIVE
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Food service is inadequate

Based on staff (S1) interview, R1 is not on a special diet and they would serve whatever R1 requests and they would offer R1 snacks too. They would serve the food to R1, sometimes R1 would say OK and eat it and sometimes R1 would ask for something else then change mind again. Sometimes R1 would ask for a specific type and amount of food and they would provide it for R1. They would place the food on R1’s table and S1 checks to make sure R1 eats it and sometimes would have to co-ax R1 to eat a few bites otherwise, R1 wouldn’t eat the food.

Based on FM’s interview, R1’s MD is aware that R1 is not eating much and have discussed with R1 the importance of R1 drinking more fluids. R1 refuses to drink stating that the water tastes like plastic.

Resident's underpants are too big

Based on staff (S1) interview, R1 likes to stay in bed most of the time and when R1 is lying down, the undergarment should be loose otherwise the moisture around the private area would cause more problems. R1 has been using the same size undergarment since R1 was admitted at the facility. When they tried to use a smaller size undergarment, R1 would tear it up so they switched back to the size R1 was using before.

Yard is cluttered with debris

On 04/12/21, LPA conducted a video call with S1 via FaceTime to check the facility yard. LPA observed walkers and wheelchairs in the yard. S1 stated that equipment were being used by the residents including R1. LPA observed yard pathway is clear of obstruction.

Continued LIC9099-C.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Joanne Roadilla
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 26-AS-20210402135914
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 1
FACILITY NUMBER: 435202790
VISIT DATE: 09/13/2021
NARRATIVE
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The department has completed the investigation of the above allegations. Based on interviews, observations and records review, there is no preponderance of evidence to prove the allegations did or did not occur. Therefore, the Department found the above allegations to be UNSUBSTANTIATED.

No deficiencies cited during today's visit. Report was discussed with and a copy provided to Carmen Buno.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Joanne Roadilla
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021
LIC9099 (FAS) - (06/04)
Page: 7 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
04/02/2021 and conducted by Evaluator Joanne Roadilla
COMPLAINT CONTROL NUMBER: 26-AS-20210402135914

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: 5DATE:
09/13/2021
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Carmen BunoTIME COMPLETED:
06:15 PM
ALLEGATION(S):
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Facility ramp railing unsteady.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Joanne Roadilla conducted an unannounced Complaint Investigation to deliver the investigation findings on the above allegations. LPA met with Administrator Carmen Buno and discussed the purpose of the visit.

On 04/02/21, the department received a complaint with the above allegations. On 04/12/21, LPA conducted an initial 10-day investigation tele-visit. LPA interviewed 5 staff (S1-S5) and requested for residents’ records.

On 04/12/21, LPA conducted a video call with S1 via FaceTime to check the facility yard. LPA observed S1 walk through the ramp and hold the railing. The railing was observed to wiggle only when shaken hard by S1. Continued on LIC9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Joanne Roadilla
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 26-AS-20210402135914
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 1
FACILITY NUMBER: 435202790
VISIT DATE: 09/13/2021
NARRATIVE
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On 09/13/21, LPA verified with facility staff that the facility has not had any renovations since April 2021. At around 5:30pm, LPA toured the facility backyard with ADM. LPA observed with ADM that one of the ramp railings located on the left side of the backyard is wobbly.

The Department has completed the investigation of the above allegation. Based on observations, the preponderance of evidence standard has been met for the above allegations. Therefore, the Department found the above allegations to be SUBSTANTIATED.

Deficiencies cited per the California Code of Regulations Title 22, see attached 9099-D. Citation, Plan of Correction and Appeal Rights were discussed, and a copy of reports provided to Carmen Buno.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Joanne Roadilla
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 26-AS-20210402135914
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 1
FACILITY NUMBER: 435202790
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/27/2021
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidenced by:
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ADM agreed to fix the railings by POC due date.
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Based on observation, one of the ramp railings located on the left side of the backyard is wobbly. This poses a potential health risk to residents 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.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Joanne Roadilla
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 7