015600118-12-11-2023-15-AS-YFLS-CYYVPT-20231229153715

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015600118
Report Date: 12/11/2023
Date Signed: 12/11/2023 10:22:13 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 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
10/10/2023 and conducted by Evaluator Paris Watson

COMPLAINT CONTROL NUMBER: 15-AS-20231010162801

FACILITY NAME:	CARLTON PLAZA OF FREMONT		FACILITY NUMBER:	015600118
ADMINISTRATOR:	GEUL, MEGHIAN E		FACILITY TYPE:	740
ADDRESS:	3800 WALNUT AVENUE		TELEPHONE:	(510) 505-0555
CITY:	FREMONT	STATE: CA	ZIP CODE:	94538
CAPACITY:	128	CENSUS: 94	DATE:	12/11/2023
		UNANNOUNCED	TIME BEGAN:	09:55 AM
MET WITH:	Mae Brown, Resident Liaison Yaritza Yanez, Care Manager		TIME COMPLETED:	10:40 AM

ALLEGATION(S):

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Residents were molested while in care
Resident sustained injury while in care
Staff did not seek medical attention for the resident

INVESTIGATION FINDINGS:

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On 12/11/2023 at 9:55 AM, Licensing Program Analyst P Watson arrived unannounced deliver findings for the above allegations. LPA met with Resident Liaison, Mar Brown and Care Manager, Yaritza Yanez and explain the purpose of the visit

During the course of the investigation, LPA L. Fici requested and obtained the facilities current staff schedule, personnel report (LIC 500), facility sketch, most recent physicians report, evaluation and service plan, admission agreements, any unusual Incident Reports (LIC 624) for October 2023, case notes for October 2023, Hospice notes, home health notes, medication log, and emergency and identification information. In addition, current staffing roster with contact information.

Report continues on 9099 C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris Watson	TELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023

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-20231010162801

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CARLTON PLAZA OF FREMONT	FACILITY NUMBER: 015600118
	VISIT DATE: 12/11/2023

NARRATIVE

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It was alleged that, Residents were molested while in care.

Based on interview with resident (R1), R1 stated that two men came into their room at night to offer them water and a diaper change, R1 felt uncomfortable by the two men and expressed to them that they did not want the two men to come into their room anymore. R1 learned that those two men were R2 and R2’s brother, and not facility staff. R1 did not disclose abuse of any kind by facility staff.

It was alleged that, Resident sustained injury while in care.

Based on record review, staff (S1) tried to care for R2, but was unable to due to R1 not allowing S1 to render care to R2. R1 pulled on S1 and cut their finger, S1 gave R1 a bandage and suggested they be evaluated due to their behavior and injury.

It was alleged that, Staff did not seek medical attention for the resident.

Based on record review, S1 provided first aid to R1 and evaluated them when they injured themselves, based on the injury facility staff did not call EMS for R1.

Based on interviews and record review, although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris Watson	TELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023

LIC9099 (FAS) - (06/04)

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