015600118-1-8-2025-15-AS-PMAO-DCR38M-20250108170146

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015600118
Report Date: 01/08/2025
Date Signed: 01/08/2025 05:02:01 PM

Document Has Been Signed on 01/08/2025 05:02 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	CARLTON PLAZA OF FREMONT		FACILITY NUMBER:	015600118
ADMINISTRATOR/ DIRECTOR:	GEUL, MEGHIAN E		FACILITY TYPE:	740
ADDRESS:	3800 WALNUT AVENUE		TELEPHONE:	(510) 505-0555
CITY:	FREMONT	STATE: CA	ZIP CODE:	94538
CAPACITY: 128	TOTAL ENROLLED CHILDREN: 0	CENSUS: 123	DATE:	01/08/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Meghian Geul, Executive Director		TIME VISIT/ INSPECTION COMPLETED:	04:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 01/08/2025 at 9:30 AM, Licensing Program Analysts (LPAs) P. Manalo and K. Nguyen arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Executive Director, Meghian Geul, and explained the purpose of the visit. The facility’s fire clearance was approved for capacity of 128 residents and 77 of those residents may be non-ambulatory. The facility is also approved for hospice waivers of 6. LPAs toured the facility inside and out including but not limited to 4 residents' apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPAs observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 69 degrees F. The hot water temperature in a sample of residents’ shared bathroom were measured at 109.2, 115.5, 108.2 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats/ non-skid shower pan. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 02/08/2024 all around the facility. Emergency disaster drill was last conducted on 12/30/2024. At 01:16 PM, LPAs reviewed 6 residents records. At 11:30 AM, LPAs reviewed 6 staff records and 6 of 6 have current first aid training and associated to the facility. At 3:00 PM, LPAs reviewed two sample of resident’s medications. Continue from LIC 809-C...

Yvonne Flores-Larios	TELEPHONE: (510) 286-4201
Patricia Manalo	TELEPHONE: (916) 432-7785
	DATE: 01/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025

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 01/08/2025 05:02 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
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: 01/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Storage Space and Access

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having a knife in R2's room, Lysol spray and dish soap in R3's room, and cleaning supplies such as Lysol spray and the Pink Stuff in R1's room which poses an immediate health and safety risk to persons in care.
	POC Due Date: 01/09/2025
	Plan of Correction
1 2 3 4	The Executive Director agrees to remove the following items and send proof to CCLD by POC date.

Section Cited

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having prescribed medication of solution in R1's bathroom which poses an immediate health and safety risk to persons in care.
	POC Due Date: 01/09/2025
	Plan of Correction
1 2 3 4	Executive Director agrees remove the medication from the resident's room, and send proof to CCLD by POC date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Yvonne Flores-Larios	TELEPHONE: (510) 286-4201
Patricia Manalo	TELEPHONE: (916) 432-7785
	DATE: 01/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/08/2025 05:02 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
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: 01/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Incidental Medical and Dental Care Services

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in not having a PRN medication for R2 in the Med Tech room and in R2's medication bin, there was medication found not listed in doctor's order which poses a potential health and safety risk to persons in care.
	POC Due Date: 01/22/2025
	Plan of Correction
1 2 3 4	Executive Director agrees to obtain a discontinued order for both medications and send proof to CCLD by POC date.

Section Cited

Incidental Medical and Dental Care Services

(8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above in having an incomplete first aid kid in the second floor, third floor, and in the kitchen which poses a potential health and safety risk to persons in care.
	POC Due Date: 01/22/2025
	Plan of Correction
1 2 3 4	Executive Director agrees to obtain a complete first aid kit in each level of the facility and send proof to CCLD by POC date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Yvonne Flores-Larios	TELEPHONE: (510) 286-4201
Patricia Manalo	TELEPHONE: (916) 432-7785
	DATE: 01/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 01/08/2025

NARRATIVE

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Continue form LIC809...

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 01/22/2025:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:

At 10:20 AM, LPAs observed a knife in R2's room.

At 10:33 AM, LPAs observed Lysol spray and multiple bottles of dish soap in the R3's bathroom.

At 10:37 AM, LPAs observed cleaning supplies such as Lysol spray and The Pink Stuff.

At 10:38 AM, LPAs observed prescribed solution in R1's bathroom.

At 10:45 AM, LPAs observed that the second floor, third floor, and kitchen did not have a full complete first aid kit.

At 3:15 PM, LPAs observed that R2 did not have his PRN medication in the Med Tech room.

At 3:20 PM, LPAs observed R2 does not have a doctor's order for a medication that was found on his medication bin that labeled R2's room number.

The Facility was cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted with Executive Director. Appeal Rights and a copy of this report provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME: Patricia Manalo	TELEPHONE: (916) 432-7785
LICENSING EVALUATOR SIGNATURE:	DATE: 01/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025

LIC809 (FAS) - (06/04)

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