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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015600341
Report Date: 03/05/2025
Date Signed: 03/05/2025 01:13:35 PM

Unsubstantiated


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
12/02/2024 and conducted by Evaluator Laura Hall
COMPLAINT CONTROL NUMBER: 15-AS-20241202105003
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: 90DATE:
03/05/2025
UNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Jocelynn Ahnstrom, Director of Resident ServicesTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff hit resident
INVESTIGATION FINDINGS:
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On 3/5/2025 at 12:40pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to deliver complaint findings for the allegation above. LPA met with Jocelynn Ahnstrom, Director of Resident Services and explained the reason for the visit.

During the course of the investigation the Department conducted interviews with staff, witnesses, resident, obtained and reviewed records.

Allegation: Staff hit resident

Based on interview with W1 it was stated she was told by R1 that R1 was hit by a male caregiver (S4) while sleeping. W1 then reported conversation with R1 to facility

Continued on LIC9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2025
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-20241202105003
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: 03/05/2025
NARRATIVE
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Continued from LIC9099.

staff. R1 stated during interview that S4 did not say anything just hit her 3xs in the chest. On December 10, 2024, facility staff was interviewed. S2 stated S4 worked the overnight shift through a registry. S2 also stated the appropriate agencies were notified of the allegation. S3 stated S4 had only worked two (2) shifts with the facility. S3 had received positive feedback from other staff when S4 worked the previous shift. S3 stated he immediately removed S4 from the registry database after receiving the allegation. The day following the allegation S3 went to R1’s room. S3 stated there was not any observation of swelling, bruises, or abrasions on R1. S5 stated during interview that the night of the allegation S4 was assigned to R1. S5 also stated R1 is a 2-person assist with toileting, therefore, both (S4 and S5) went into R1’s room that night together to assist R1, which R1 refused. R1 was asleep when they entered the room. S4 stated he was not aware of any allegation towards him during interview. Review of R1’s individual service plan dated November 10, 2024, indicates R1 has a pendent to push in care of an emergency.

Based on record review of the San Leandro Police Department report dated November 30, 2024, there was no evidence of injury or in-room or hallway cameras that would have captured any portion of the incident.

Based upon the information obtained and the interviews conducted during the investigation, the above allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted and a copy of report was given.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2