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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015600118
Report Date: 08/05/2025
Date Signed: 08/05/2025 03:46:05 PM

Substantiated


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
04/29/2025 and conducted by Evaluator Patricia Manalo
COMPLAINT CONTROL NUMBER: 15-AS-20250429090259
FACILITY NAME:CARLTON PLAZA OF FREMONTFACILITY NUMBER:
015600118
ADMINISTRATOR:AMARI, GIANNIFACILITY TYPE:
740
ADDRESS:3800 WALNUT AVENUETELEPHONE:
(510) 505-0555
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY:128CENSUS: 123DATE:
08/05/2025
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Gianni Amari, Executive Director TIME COMPLETED:
04:10 PM
ALLEGATION(S):
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Staff do not report incidents to appropriate parties
INVESTIGATION FINDINGS:
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On 08/05/2025 at 9:10 AM, Licensing Program Analysts (LPAs) P. Manalo and K. Nguyen arrived unannounced to gather additional information, conducted interviews, and deliver the findings on the above allegation.

During the course of the investigation, LPA P. Manalo interviewed Executive Director (ED), Reporting Party (RP), Residents, Staff, and Witness. LPAs obtained the following documents such as Admission Agreement, Resident Daily Log, Resident Service Plan dated 03/09/2025, Email Correspondence between Resident 1’s (R1’s) RP and staff members, Family Care Conference dated 04/03/2025, Medication Administration Report (MAR), Medication Verification, Resident Roster, R1’s Call Log from 04/23/2025 to 04/29/2025, Resident Continence Care Log, Carlton HSE Results dated 03/09/2025, Internal Incident Report dated 03/09/2025 and 04/23/2025, Physician Report dated 10/02/2023, Carlton’s Invoice, Service Plan dated 02/04/2025, Staff Schedule, and Staff Roster.

Continue to LIC9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 15-AS-20250429090259
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: 08/05/2025
NARRATIVE
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Continue from LIC9099...

LPAs P. Manalo and K. Nguyen conducted interviews with 4 residents and 4 staff.


Allegation: Staff do not report incidents to appropriate parties

It was alleged that staff do not report incidents to appropriate parties. A review of R1’s Resident Daily Log dated 03/09/2025 and Internal Incident Report dated 03/09/2025 and 04/23/2025 revealed that R1 had multiple unwitnessed falls. Falls were made aware to the responsible parties, however, were not reported to the licensing department. Based on interviews conducted with S2, S2 stated that incident reports will only be reported to the licensing department if the resident was sent to the hospital or had any serious injury due to previous training from the facility.

Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 15-AS-20250429090259
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/19/2025
Section Cited
CCR
87211(a)(1)
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87211(a)(1) Reporting Requirements
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below...

This requirement is not met as evidenced by:
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The Executive Director agrees to conduct an in-service regarding reporting requirements with all staff and self-certification of the regulation. Plan of correction will be sent to CCLD by POC date.
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The licensee did not comply with the section cited above by not reporting to the licensing department of any falls that R1 had at the facility which posed 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.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
04/29/2025 and conducted by Evaluator Patricia Manalo
COMPLAINT CONTROL NUMBER: 15-AS-20250429090259

FACILITY NAME:CARLTON PLAZA OF FREMONTFACILITY NUMBER:
015600118
ADMINISTRATOR:AMARI, GIANNIFACILITY TYPE:
740
ADDRESS:3800 WALNUT AVENUETELEPHONE:
(510) 505-0555
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY:128CENSUS: DATE:
08/05/2025
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Gianni Amari, Executive Director TIME COMPLETED:
04:10 PM
ALLEGATION(S):
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Staff do not ensure that resident's incontinence needs are met
Staff do not assist resident with ambulation
Staff do not monitor resident for change in condition
Staff do not communicate with responsible party regarding resident's care
Staff handles resident in a rough manner
INVESTIGATION FINDINGS:
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On 08/05/2025 at 9:10 AM, Licensing Program Analysts (LPAs) P. Manalo and K. Nguyen arrived unannounced to gather additional information, conducted interviews, and deliver the findings on the above allegations.

During the course of the investigation, LPA P. Manalo interviewed Executive Director (ED), Reporting Party (RP), Residents, Staff, and Witness. LPAs obtained the following documents such as Admission Agreement, Resident Daily Log, Resident Service Plan dated 03/09/2025, Email Correspondence between Resident 1’s (R1’s) RP and staff members, Family Care Conference dated 04/03/2025, Medication Administration Report (MAR), Medication Verification, Resident Roster, R1’s Call Log from 04/23/2025 to 04/29/2025, Resident Continence Care Log, Carlton HSE Results dated 03/09/2025, Internal Incident Report dated 03/09/2025 and 04/23/2025, Physician Report dated 10/02/2023, Carlton’s Invoice, Service Plan dated 02/04/2025, Staff Schedule, and Staff Roster.

Continue to LIC9099-C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 15-AS-20250429090259
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: 08/05/2025
NARRATIVE
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Continue from LIC9099-A...

LPAs P. Manalo and K. Nguyen conducted interviews with 4 residents and 4 staff.

Allegation: Staff do not ensure that resident's incontinence needs are met

It was alleged that staff do not ensure that resident’s incontinent needs are met. A review of Resident’s Continence Care Services dated 04/22/2025 to 04/30/2025 showed that R1 received continence care every 2 hours. However, interviews with S3, S5, S6, and S7 stated that there are times when R1 would refuse continence care from staff. Facility’s invoice with R1’s responsible party revealed that there is a service charge pertaining to R1’s continence care from March 2025 to May 2025. Progress Notes from the Resident Daily Log also showed that S5 assisted R1 with continence care on 03/19/2025 and 03/26/2025.

Allegation: Staff do not assist resident with ambulation

It was alleged that staff do not assist resident with ambulation. Interviews with ED, S1, S3, S4, and S5 stated that R1 did not have escort services included in their Service Plan, however, staff will still assist R1 with escorting services to the dining hall when needed. Record review of the Resident Daily Log had progress notes dated 03/19/2025, 03/26/2025, and 04/24/2025 showing that R1 was provided escorted services by staff to the dining hall.

Allegation: Staff do not monitor resident for change in condition

It was alleged that staff do not monitor resident for change in condition. A record review of the Family Care Conference Progress Detail dated 04/03/2025 showed that the facility conducted a meeting with the responsible party regarding some concerns with R1’s decline of health condition. The conference included speaking with the responsible party regarding the R1’s assessment and updating R1’s service plan.

Continue to LIC9099-C...
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 15-AS-20250429090259
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: 08/05/2025
NARRATIVE
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Continue from LIC9099-C...

Allegation: Staff do not communicate with responsible party regarding resident's care

It was alleged that staff do not communicate with the responsible party regarding resident's care. Based on interviews conducted with S2, S2 stated that most of the communication between the facility and R1’s responsible party was conducted via phone call and email. Record review of text communication correspondence dated between 03/26/2025 to 03/27/2025 showed that staff communicated with R1’s responsible parties via text regarding R1’s care. Record review of email communication between R1’s responsible parties and the facility revealed that the facility communicated about R1’s care plan and continence care between September 2024 and October 2024. A record review of the Family Care Conference Progress Detail dated 04/03/2025 indicated that the facility and family had a meeting regarding R1’s care and the facility’s plan on providing that care to R1.

Allegation: Staff handles resident in a rough manner

It was alleged that Staff handles resident in a rough manner. Interviews with 4 of 4 residents stated that staff are handling them with care when providing services to the residents and have not observed or heard of any staff being rude to the residents. R2 indicated that when staff are assisting R2 with ADLs, R2 has not had any negative encounter or experiences with staff.

Based on interviews and record reviews conducted, the above allegations are unsubstantiated.

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

There is no deficiency noted.

Exit interview conducted and a copy of this report was provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6