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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600118
Report Date: 09/09/2022
Date Signed: 09/09/2022 03:40:59 PM


Document Has Been Signed on 09/09/2022 03:40 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:CARLTON PLAZA OF FREMONTFACILITY NUMBER:
015600118
ADMINISTRATOR:BRICE, STEPHANIEFACILITY TYPE:
740
ADDRESS:3800 WALNUT AVENUETELEPHONE:
(510) 505-0555
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY:128CENSUS: 111DATE:
09/09/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Administrator- Meghian GeulTIME COMPLETED:
03:50 PM
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On today’s date at 2:45 PM. Licensing Program Analyst (LPA) L. Fici and Licensing Program Manager (LPM) Y. Flores-Larios arrived unannounced to conduct a case management visit. LPA and LPM met Administrator (ADM), Meghian Geul and explained the purpose of the visit.

LPA received an incident report dated of incident that occurred on 8/22/2022 regarding S1 using profanity towards R1 while assisting R1. Facility reported incident timely and completed all mandatory cross reporting as required. Facility S1 on administrative leave; pending investigation. LPA & LPM received a copy of the S1's statement regarding the incident. A review was conducted of S1 and R1's file. S1 has required training on file and is current. After facility conducted internal investigation, S1 was terminated on 8/26/2022 from the facility. S1 denies profanity was used towards R1 however facility had reviewed video footage from R1's sister which audio is clear on profanity being used. Facility conducted in-service training for all staff regarding resident's rights.

No deficiencies are being cited on this date, Exit interview conducted with Administrator and a copy of report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon FiciTELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2022
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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