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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600341
Report Date: 09/16/2024
Date Signed: 09/24/2024 01:22:42 PM


Document Has Been Signed on 09/24/2024 01:22 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 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: 153DATE:
09/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Daisy Monteon Executive AssistantTIME COMPLETED:
06:30 PM
NARRATIVE
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On 9/16/2024 at 10:30 AM, Licensing Program Analysts (LPAs) David Doidge and James Sampair arrived unannounced to conduct the Required Annual Inspection. Upon entry, LPAs stated the purpose of the visit to Daisy Monteon Executive Assistant at 10:40 AM.

LPAs toured the facility including but not limited to bedrooms, bathrooms, dining area, activity rooms, kitchen, common areas, and outdoor area. Centrally stored medications were locked in medication carts located in med rooms. Smoke detectors were interconnected with sprinkler system. Carbon monoxide detectors were observed. Fire extinguishers were observed to be full and last serviced on 09/01/2024. Temperature in the facility was measured at 74.0 degrees Fahrenheit at 10:51 AM. Water temperature is 112 degrees Fahrenheit.

The LPAs observed required postings in the facility, including the Complaint Poster, Ombudsman and Personal Rights posters, and the Theft and Loss Policy. An administrator is on site more than the minimum of 20 hours a week to oversee the proper business operations.

Grab bars for each toilet and shower were installed. Non-skid mats were observed. There were adequate lights in each room. Resident rooms were observed to be cleaned and fully furnished. Indoor and outdoor passages were free of obstruction.


One week of nonperishable and 2 days of perishable food supplies were available. Facility orders food twice a week.

1 B-type citation issued.

Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME: David DoidgeTELEPHONE: (916) 475-5913
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2024
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 2


Document Has Been Signed on 09/24/2024 01:22 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 SAN LEANDRO
FACILITY NUMBER: 015600341

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(e)
Care of Persons with Dementia
(e) Swimming pools and other bodies of water shall be fenced and in compliance with state and local building codes.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in two (2) of two (2) fountains which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/23/2024
Plan of Correction
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To fill bodies of water with rock and send a picture to LPA
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME: David DoidgeTELEPHONE: (916) 475-5913
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2