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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015600341
Report Date: 08/26/2020
Date Signed: 08/26/2020 12:24:01 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
03/31/2020 and conducted by Evaluator Treana White
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20200331143351
FACILITY NAME:CARLTON PLAZA OF SAN LEANDROFACILITY NUMBER:
015600341
ADMINISTRATOR:NANCY RANDHAWAFACILITY TYPE:
740
ADDRESS:1000 EAST 14TH ST.TELEPHONE:
(510) 636-0660
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY:199CENSUS: 145DATE:
08/26/2020
UNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Nancy Randhawa, AdministratorTIME COMPLETED:
12:20 PM
ALLEGATION(S):
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Lack of supervision resulting in death of resident.
INVESTIGATION FINDINGS:
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On 08/26/2020, Licensing Program Analyst (LPA) T. White called the facility to deliver the complaint findings for the above allegation. LPA spoke with Administrator, Nancy Randhawa. LPA explained due to the present shelter in place order by the Governor, the notification of the complaint is being done over the phone.

During the course of investigation, IB investigator conducted interviews, collected video camera footage, police report, and obtained information in relation to the complaint. Based on video camera footage, Resident #2 (R2) pushed Resident #1 (R1) in the chest and R1 fell backwards to the ground hitting his head. The video camera showed one staff member walking towards R1 and R2 when R1 was pushed. Once R1 fell, three staff members immediately came into the camera view when R1 fell to the ground.

Report continues on 9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2020
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 2
Control Number 15-AS-20200331143351
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 SAN LEANDRO
FACILITY NUMBER: 015600341
VISIT DATE: 08/26/2020
NARRATIVE
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IB was unable to conduct interviews with both residents because R1 was unconscious and R2’s dementia diagnosis. Based on Staff #2 (S2) interview with IB, R1 and R2 did not have violent behaviors prior to this incident. However, S2 stated both residents were unpredictable which resulted in the death of a resident.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted with Administrator and a copy of report emailed to facility.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 2