<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600341
Report Date: 04/26/2024
Date Signed: 04/26/2024 04:32:06 PM


Document Has Been Signed on 04/26/2024 04:32 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



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: 148DATE:
04/26/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Evelyn Jensen, Executive DirectorTIME COMPLETED:
04:45 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 04/26/2024 at 3:00pm, Licensing Program Analyst (LPA) L. Alexander conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 04/03/2024. LPA met with Executive Director, Evelyn Jensen and explained the purpose of the visit.

S1 stated that S2, the "Care Partner" for R1, reported to S3 that on 03/10/24 R1 said something that was sexual in nature to S2 after he asked R1 if they were ready for their shower. S1 stated that S3 went to R1 to speak with them but couldn't make out what R1 was saying. S1 stated that they called 911 and San Leandro PD was dispatch (Ref. 2024-12242). S1 stated that the police came to investigate the 911 call and when the police arrived to speak with R1 they also could not make out any understanding of what R1 was saying. S1 indicated that S2 was immediately taken off the care shower schedule for R1. S1 indicated that R1 is refusing care from the other Care Partners but R1 is not making any sexual natured statements neither.

No deficiencies issued during the visit.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1