015600118-5-7-2026-15-AS-BFOG-DWV45M-20260811184810

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015600118
Report Date: 05/07/2026
Date Signed: 05/07/2026 02:26:15 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
01/23/2026 and conducted by Evaluator Patricia Manalo

COMPLAINT CONTROL NUMBER: 15-AS-20260123080421

FACILITY NAME:	CARLTON PLAZA OF FREMONT		FACILITY NUMBER:	015600118
ADMINISTRATOR:	AMARI, GIANNI		FACILITY TYPE:	740
ADDRESS:	3800 WALNUT AVENUE		TELEPHONE:	(510) 505-0555
CITY:	FREMONT	STATE: CA	ZIP CODE:	94538
CAPACITY:	128	CENSUS: 128	DATE:	05/07/2026
		UNANNOUNCED	TIME BEGAN:	08:55 AM
MET WITH:	Gianni Amari		TIME COMPLETED:	12:55 PM

ALLEGATION(S):

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Staff did not provide proper food service to resident in care
Staff did not ensure that the facility had telephone services for residents in care
Passageways accessible to residents in care is not kept free of obstructions
Staff did not provide adequate care and supervision
Facility elevator is in disrepair
Staff provided the wrong medication to resident in care
Resident was not provided with contracted facility amenities
Staff left resident unattended resulting in a fall
Staff did not implement proper infection control practices
Staff exposed residents to a hazardous chemicals

INVESTIGATION FINDINGS:

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On 05/07/2026 at 8:55 AM, Licensing Program Analyst (LPA) P. Manalo arrived unannounced to conducted more interviews and deliver the findings on the above allegations. LPA met with Executive Director, Gianni Amari, and explained the purpose of the visit.

During the course of investigations, LPA interviewed ED, S1, S2, S3, S4, S5, S6, S7, S8, S9, S10, and R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, and R12. LPA also interviewed W1, W2, and W3. LPA toured the facility, collected and reviewed documents including but not limited to resident roster, email correspondence, elevator invoices, housekeeping schedules, Personnel Report (LIC500), facility incident report, service plan, facility’s medication verification/ doctor’s order, pharmacy contact information, residents' Admission Agreement, Physician Report, Resident Health Identification Information, Service Plans, Facility Incident Report notes, Email Correspondence of Maintenance Issue, Email Correspondence of Health Outbreaks, Amenities Documentation, Residents' Monthly Invoice,

Continue to LIC9099-C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2026

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-20260123080421

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: CARLTON PLAZA OF FREMONT	FACILITY NUMBER: 015600118
	VISIT DATE: 05/07/2026

NARRATIVE

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January Food Menu, and Monthly Task Log.

Allegation: Staff did not provide proper food service to resident in care.

It was alleged that staff did not provide proper food service to resident in care. Interview with 10 of 12 residents indicated that the food is cooked well and that they haven’t had any issues with uncooked or raw food. Interview with S2 revealed the kitchen staff will use a food thermometer to check if it’s cooked thoroughly and once the food is cooked, kitchen staff will place it in a food warmer before meal services.

Based on interviews conducted, the above allegation that staff did not provide proper food service to resident in care is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

Allegation: Staff did not ensure that the facility had telephone services for residents in care.

It was alleged that staff did not ensure that the facility had telephone services for residents in care. Interview with W2 indicated that someone at the front desk will usually either pick up or call back right away if W2 calls the facility. W2 indicated that they have not experienced any issues getting ahold of someone in the facility when needed. Interview with R1 stated that R1 has an Alexa and a cellphone in their room. LPA observed that R1 has two Alexa in the room. In addition, Interview with R11 revealed that R11 was provided with Alexa services and R11 can use Alexa to call staff for assistance. On 02/05/2026, LPA observed that R11 used Alexa to call staff for assistance and staff responded right away.

Based on interviews and observations conducted, the above allegation that staff did not ensure that the facility had telephone services for residents in care unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

Continue to LIC9099-C...

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2026

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20260123080421

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: CARLTON PLAZA OF FREMONT	FACILITY NUMBER: 015600118
	VISIT DATE: 05/07/2026

NARRATIVE

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Continued from LIC9099-C...

Allegations: Passageways accessible to residents in care is not kept free of obstructions.

It was alleged that passageways accessible to residents in care is not kept free of obstructions. On 01/30/2026, LPA observed that there was a dumpster bin outside in the parking lot away from the passageway. On 04/28/2026, LPA P. Manalo and K. Nguyen observed multiple trash bins outside in the parking lot away from the passageway. Interview with S6 indicated that when the trash and recycle is scheduled to be picked up, the gate will be open until it’s done. S6 stated that the side gate will only be opened during the scheduled pick-up day. Interview with W2 indicated that there have been no issues with the handicapped area in the parking lot being blocked off with anything. Interview with R4 and R5 stated that they use the handicapped parking in the back parking lot frequently and never had any issues with the passageway blocked. R4 stated that there were trash bins outside in the parking lot at times, but it never blocked the passageway to enter the facility. 5 of 5 residents interviewed revealed that they never encountered any issues with passageways blocked inside and outside of the facility.

Based on interviews and observations conducted, the above allegation that passageways accessible to residents in care are not kept free of obstructions is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

Allegation: Staff did not provide adequate care and supervision

It was alleged that staff did not provide adequate care and supervision. Interviews with 9 of 12 all indicated that they are getting the care that they need at the facility. Interview with 2 of 12 residents indicated that they are independent and don’t require any care and supervision from the staff. Interview with W2 and W3 indicated that there are no issues with care in the facility for their residents. During interview with R1, R1 stated that R1 is comfortable and that the facility takes good care of R1.

Continue to LIC9099-C...

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2026

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20260123080421

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: CARLTON PLAZA OF FREMONT	FACILITY NUMBER: 015600118
	VISIT DATE: 05/07/2026

NARRATIVE

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R1 also included that the staff is assisting and meeting the needs of R1.

Based on interviews conducted, the above allegation that staff did not provide adequate care and supervision is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

Allegation: Facility elevator is in disrepair.

It was alleged that the facility elevator is in disrepair. On 10/21/2025, LPA received an email from ED that the elevator in the back of the facility will be undergoing maintenance for approximately 6 weeks. Per email, it indicated that there will be two other elevators that residents and visitors can use in the meantime. On 01/30/2026, LPA observed that the elevator in the back was still undergoing maintenance per signage posted on the elevator. On 04/28/2026, LPA P. Manalo and K. Nguyen observed 2 of 3 elevators functioning and 1 of 3 elevators undergoing repair. Interview with ED on 04/28/2026 indicated that with the elevators constantly in repair, the facility decided to do a modernization for all 3 elevators. Interview with 5 of 5 residents indicated that all 3 elevators have not been out of service all at once and that at least one elevator is in use for the residents.

Based on interviews and observations conducted, the above allegation that facility elevator is in disrepair is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

Allegation: Staff provided the wrong medication to resident in care.

It was alleged that staff provided the wrong medication to residents in care. Interview with 5 of 5 residents that are receiving medication management all stated that they have received their medication on time and don’t think they’ve received the wrong medication. R1 stated that staff will hand R1 their medication and will wait until R1 has taken it. R1 also stated that they never had any issues with their medication.
Continue to LIC9099-C...

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2026

LIC9099 (FAS) - (06/04)

Page: 4 of 7

Control Number 15-AS-20260123080421

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: CARLTON PLAZA OF FREMONT	FACILITY NUMBER: 015600118
	VISIT DATE: 05/07/2026

NARRATIVE

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Based on interviews and observations conducted, the above allegation that staff provided the wrong medication to resident in care is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

Allegation: Resident was not provided with contracted facility amenities.

It was alleged that the resident was not provided with contracted facility amenities. A review of R1’s admission agreement dated on 02/01/2022 revealed that the utilities provided for R1 will only include water, electricity, garbage service, heat and air conditioning. The residents will be responsible for their own installation of other services such as telephone or cable. Interview with R1 says that they have a cellphone to use if needed. Interview with 4 residents stated that there are Wi-Fi connections provided by the facility for residents to use in the common areas such as the café or the library.

Based on review of documents and interview conducted, the above allegation that resident was not provided with contracted facility amenities is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

Allegation: Staff left resident unattended resulting in a fall.

It was alleged that staff left residents unattended resulting in a fall. A review of the facility’s internal incident report dated 03/26/2026 indicated that R1 pressed their pendant and staff found R1 sitting on the floor beside R1’s bed. R1 was reported to have slid off the bed and felt okay. Per incident report, the facility staff notified R1’s responsible party and R1 did not sustain any injuries.

Continued to LIC9099-C....

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2026

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20260123080421

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: CARLTON PLAZA OF FREMONT	FACILITY NUMBER: 015600118
	VISIT DATE: 05/07/2026

NARRATIVE

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Based on review of documents conducted, the above allegation that staff left resident unattended resulting in a fall is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

Allegation: Staff did not implement proper infection control practices.

It was alleged that staff did not implement proper infection control practices. A review of the facility’s incident report dated 11/21/2024 indicated that R1 along with multiple other residents had symptoms of norovirus. However, a review of other incident reports does not indicate that R1 was positive from other previous outbreaks in 2024 and 2025. Interviews with S7 and S9 indicated that when there is an infectious outbreak in the facility, Personal Protective Equipment (PPE) is worn before going inside a residents’ room. A review of email correspondence from ED to LPA indicates that when there is an outbreak, the ED will report to Local Public Health (LPH) of the outbreak and get recommendations on what to do. Interview with 5 of 5 residents revealed that staff have been observed to be using PPE supplies before. In addition, interview with R2 indicated that staff were using gloves while assisting with their showers.

Based on interviews and observations conducted, the above allegation that staff did not implement proper infection control practices is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

Allegation: Staff exposed residents to a hazardous chemicals.

It was alleged that staff exposed residents to a hazardous chemical. On 01/30/2026, LPA P. Manalo conducted a tour around the facility and did not observe any hazardous chemicals. On 04/28/2026, LPA P. Manalo and K. Nguyen did not observe any foul odor or hazardous chemicals being used throughout the facility.

Continue to LIC9099-C...

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2026

LIC9099 (FAS) - (06/04)

Page: 5 of 7

Control Number 15-AS-20260123080421

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: CARLTON PLAZA OF FREMONT	FACILITY NUMBER: 015600118
	VISIT DATE: 05/07/2026

NARRATIVE

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Interview with ED, S3, and S4 all indicated that R1 has their own cleaning products that housekeepers will use to clean R1’s room. Furthermore, S3 stated that housekeepers will dilute the cleaning products with water before using. 6 of 9 residents interviewed all indicated that they do not have any issues with the type of cleaning chemicals that are used. Interview with S7 revealed that when housekeeping is scheduled for that day, S7 will open R1’s windows and bring R1 down to the common area. S7 stated that by the time R1 is returned to R1’s room, there is no smell. Furthermore, interview with R1 revealed that the facility uses the cleaning products in R1’s room for cleaning.

Based on interviews and observations conducted, the above allegation that staff exposed residents to a hazardous chemical is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

No deficiencies cited.

Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2026

LIC9099 (FAS) - (06/04)

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