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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600118
Report Date: 07/15/2021
Date Signed: 07/15/2021 12:38:24 PM


Document Has Been Signed on 07/15/2021 12:38 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: DATE:
07/15/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Stephanie Brice, Executive DirectorTIME COMPLETED:
12:45 PM
NARRATIVE
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On 7/15/2021 at 9:40AM, Licensing Program Analyst (LPA) L. Hall conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 7/8/2021. LPA met with Stephanie Brice, Executive Director (ED) and explained the purpose of the visit.

Incident report dated 7/8/2021 revealed that S3 handled R1 roughly and abusively. Facility notified law enforcement and R1's responsible party.

LPA interviewed two (2) staff, three (3) residents, obtained and reviewed documents provided which included physician's report, S3's statement, Fremont Police report number, appraisal needs and services, staff schedule and residents roster. During interviews S1 stated that S3 should have requested a 2nd caregiver to assist with R1. The three (3) residents stated that a couple of the staff handles them roughly but did not know the names of the staff.

Based on LPAs' interviews and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D

Exit interview conducted. Appeal rights and a copy of this report provided.


SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2021
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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Document Has Been Signed on 07/15/2021 12:38 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
07/22/2021
Section Cited

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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities...(3) To be free from punishment...abuse, or other actions... This requirement was not met as evidence by:
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Based on LPA's interviews licensee did not comply wi tthe section cited above which poses a potential health and safety 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.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2021
LIC809 (FAS) - (06/04)
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