015600118-11-23-2021-15-AS-KHOS-CJVU7V-20221004152035

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015600118
Report Date: 11/23/2021
Date Signed: 11/23/2021 05:54:12 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/02/2020 and conducted by Evaluator Grace Luk

COMPLAINT CONTROL NUMBER: 15-AS-20201102110340

FACILITY NAME:	CARLTON PLAZA OF FREMONT		FACILITY NUMBER:	015600118
ADMINISTRATOR:	BRICE, STEPHANIE		FACILITY TYPE:	740
ADDRESS:	3800 WALNUT AVENUE		TELEPHONE:	(510) 505-0555
CITY:	FREMONT	STATE: CA	ZIP CODE:	94538
CAPACITY:	128	CENSUS: 112	DATE:	11/23/2021
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Stephanie Brice, Executive Director		TIME COMPLETED:	06:10 PM

ALLEGATION(S):

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Staff do not answer residents call button in a timely manor
Staff leave resident in soiled diapers
Insufficient staffing
Staff do not provide meals to resident on time

INVESTIGATION FINDINGS:

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On 11/23/2021 at 12:45PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct complaint investigation and deliver complaint findings for the allegations above. LPA met with Executive Director, Stephanie Brice.

During the investigation, LPA interviewed residents and staff. LPA obtained and reviewed staff schedule, call button logs, pendant policy, incontinence procedures, 3 resident's files including physician's report, care plan, and recorded care reports.

Staff do not answer residents call button in a timely manor:
Reviewing the pendant policy indicated that staff should respond to pendant calls in a timely manner. Reviewing call button logs revealed that majority of the staff responded to the calls within 20 minutes. Interview with staff revealed sometimes staff have issues while resetting the pendant. Interview with residents revealed staff respond to the call within a reasonable time frame. (Continue on LIC9099C...)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 11/23/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20201102110340

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 FREMONT	FACILITY NUMBER: 015600118
	VISIT DATE: 11/23/2021

NARRATIVE

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Staff leave resident in soiled diapers:
Interview with residents revealed that staff would assist with incontinence care as needed. Residents did not indicate they were left in soiled diapers. Interview with staff revealed that incontinence care is every 2-3 hours. Reviewing recorded care reports revealed that residents were checked for incontinence care 2-4 hours.

Insufficient staffing:
Reviewing staff schedules revealed that there's 6-7 staff in the morning shift, 5 staff in the afternoon shift, and 2 staff in the night shift. Interview with staff indicated there are 7 staff in the morning shift, 5 staff in the afternoon shift, and 2 staff in the night shift. Interview with residents revealed there's enough staff at the facility.

Staff do not provide meals to resident on time:
Interview with residents revealed that meals were delivered at a reasonable time. Residents stated that meals were given if they wanted food during mealtimes.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore these allegations are UNSUBSTANTIATED.

Exit interview conducted. A copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 11/23/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021

LIC9099 (FAS) - (06/04)

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