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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202790
Report Date: 09/13/2021
Date Signed: 09/14/2021 08:51:01 AM

Document Has Been Signed on 09/14/2021 08:51 AM - 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: 5DATE:
09/13/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Carmen BunoTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Joanne Roadilla conducted an unannounced case management visit today. LPA met with Administrator (ADM) Carmen Buno.

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.

On 08/03/21, LPA interviewed ADM Dina Domingo, ADM Carmen Buno and 2 staff (S1 - S2), reviewed and obtained copies of R1's records. LPA also interviewed R1.

On 09/09/21, LPA interviewed staff (S3). On 09/13/21, LPA interviewed staff (S4).

Based on ADM and staff interviews, 4 out of 4 stated that they did not witness an abuse of R1 by one of the staff at the facility. S3 and S4 stated that they both provide care for R1 together since R1 was admitted at the facility and they are never alone when caring for R1.

The department has completed the investigation of this incident. Based on interviews 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
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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