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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202790
Report Date: 03/27/2025
Date Signed: 03/27/2025 03:28:29 PM

Document Has Been Signed on 03/27/2025 03:28 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 1FACILITY NUMBER:
435202790
ADMINISTRATOR/
DIRECTOR:		DINA DOMINGO & CARMEN BUNOFACILITY TYPE:
740
ADDRESS:159 BLAKE AVETELEPHONE:
(669) 309-9724
CITY:SANTA CLARASTATE: CAZIP CODE:
95051
CAPACITY: 6CENSUS: 4DATE:
03/27/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:35 AM
MET WITH:Administrator, Dina Domingo & Carmen BunoTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit. LPA Rai met with Administrator, Dina Domingo & Carmen Buno and stated the purpose of today's visit. LPA Rai observed 2 staff who have obtained a Criminal Record Clearance. LPA Rai observed 2 residents at the facility, 1 resident at the day program and 1 resident at the hospital.

During visit, LPA Rai toured the inside and outside of the facility. When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai observed 2 sheds in the backyard which was locked and used for storage and not habitual space. LPA Rai toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. Sharps and medications were locked in secured areas. LPA observed additional food supply areas and secured areas for cleaning supplies and laundry detergents.

LPA Rai toured the facility to include 6 resident rooms, 1 staff room, living room, dining room, kitchen and garage. 6 Out of 6 resident bedrooms had available bedding, drawers, and functioning lights. LPA Rai observed resident R1's room and exit door located in the room. Administrator (ADM) Dina Domingo removed a pole from the top of the screen door which restricted resident from using the exit door. ADM stated R1 exhibited exit seeking behaviors. LPA Rai observed a working door alarm on the exit and the door had locking capabilities. LPA Rai observe safety covers on 2 exit door knobs which hindered the residents from opening the door. ADM removed the child safety covers on the doors.

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: 03/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/27/2025
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 5
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 03/27/2025 03:28 PM - It Cannot Be Edited


Created By: Simranjit Rai On 03/27/2025 at 11:41 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 1
FACILITY NUMBER: 435202790

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/28/2025
Section Cited
CCR
87307(d)(6)

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87307 Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by:
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During visit, Administrator removed the objects (a wooden block) from the sliding exit doors track. Administrator stated to submit a written plan to ensure all indoor and outdoor passageways and stairways are free from obstruction via email by POC due date.
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Based on observation, interview and record review, the licensee did not ensure that sliding exit doors tracks were free of obstruction. LPA observed a wooden block obstructing the sliding exit door tracks which poses an immediate 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: 03/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 03/27/2025 03:28 PM - It Cannot Be Edited


Created By: Simranjit Rai On 03/27/2025 at 02:30 PM
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 1
FACILITY NUMBER: 435202790

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/03/2025
Section Cited
CCR
87507(a)

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87507 Admission Agreements
(a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any.
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 Admission Agreement is signed by POC due date. Administrator agreed and understood.
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Based on interview and record review, 1 out of 2 resident files did not contain Admission Agreement which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
04/03/2025
Section Cited
CCR87465(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, 4 out of 7 medications were 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: 03/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
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 1
FACILITY NUMBER: 435202790
VISIT DATE: 03/27/2025
NARRATIVE
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The facility bathroom had available soap, paper towels, and trash cans with lids. The hot water temperature in the bathroom and kitchen sink ranged from 117.6 - 118.1 degrees F.

Fire extinguisher was observed and inspected on 01/21/2025. Facility smoke detectors and carbon monoxide detectors were in working condition. Facility staff had disaster drills conducted on 01/03/2025 & 01/08/2025.  LPA Rai observed a complete first aid kit at the facility.

LPA Rai reviewed facility records for 2 staff and 2 residents. LPA Rai observed 1 out of 2 admission agreements were not signed by resident and/or resident's responsible party.

LPA Rai reviewed resident medications and central stored medication records. LPA Rai observed resident R1's 4 out of 7 medications were not recorded on the Centrally Stored Medication Log. Per Staff S1, R1 has been administered the medication and LPA Rai observed tablets were taken from the bottle.

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

DATE: 03/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025
LIC809 (FAS) - (06/04)
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