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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015600341
Report Date: 11/20/2024
Date Signed: 11/20/2024 05:17:09 PM

Substantiated


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
11/14/2024 and conducted by Evaluator Lisha Holmes
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20241114145918
FACILITY NAME:CARLTON PLAZA OF SAN LEANDROFACILITY NUMBER:
015600341
ADMINISTRATOR:EVELYN JENSENFACILITY TYPE:
740
ADDRESS:1000 EAST 14TH ST.TELEPHONE:
(510) 636-0660
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY:199CENSUS: 152DATE:
11/20/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Evelyn Jensen, Executive DirectorTIME COMPLETED:
05:45 PM
ALLEGATION(S):
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Third floor of the facility has too many non-ambulatory residents.
INVESTIGATION FINDINGS:
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On 11/20/24 around 02:00 PM, Licensing Program Analyst(LPA) L.Holmes conducted a 10-day complaint investigation and met with Evelyn Jensen, Executive Director (ED) and toured the facility with Sheila Rodriguez, Sales Director.

During the course of the investigation, LPA and S2 toured the facility, the following documents were reviewed with S1: LIC 602, Ambulation Details Report, CCLD's Plan of Correction dated 10/31/24, Alameda County Fire Department Inpection/Review dated 10/25/24, and emails sent to CCLD's Staff Support for a capacity increase. LPA requested the current LIC 500 and current Resident Roster.

Allegation: SUBSTANTIATED
Third floor of the facility has too many non-ambulatory residents.

Continued in LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
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 3
Control Number 15-AS-20241114145918
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: 11/20/2024
NARRATIVE
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...continued from LIC9099C.

Third floor of the facility has too many non-ambulatory residents.
LPA and S1 reviewed the LIC602's for fifty-one (51) residents that reside on the third floor, The Ambulation Details Report revealed that there's a today of 8 non-ambulatory residents on the the third floor. The facility has two (2) non-ambulatory residents over the approved capacity of six (6) based on the LIC602s, therefore the allegation is substantiated.

An immediate civil penalty of $250 is hereby assessed for a repeat violation.

Deficiency is cited from Title 22 California Code of Regulations and listed on 9099D. Failure to submit proof of corrections by plan of correction due dates and any repeat violation within 12 month period may result in civil penalties.

Exit interview conducted, Appeal Rights, and a copy of this report provided to ED.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20241114145918
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/04/2024
Section Cited
CCR
87202(a)(1)
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87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by...fire protection services...Prior to accepting or retaining any of the following types of persons...licensee shall...obtain an appropriate fire clearance...

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Licensee to update Resident Roster, Ambulation Details Report and notify Residents/RP's of relocating to a different unit. A 60-day eviction notice is to be approved by CCLD if there is not an agreed resolution by the POC date.
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(1) Nonambulatory persons.
-This requirement is not met as evidenced by:
Based in interviews and records reviewed, the facility has 8 non-ambulatory residing on the 3rd floor but only 6 are approved which poses a potential health, safety, or personal rights 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: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3