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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015600341
Report Date: 05/23/2024
Date Signed: 05/23/2024 04:28:03 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
05/16/2024 and conducted by Evaluator James Sampair
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240516085526
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: 150DATE:
05/23/2024
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:EVELYN JENSENTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Facility staff did not provide assistance to resident.
Facility staff charged for services not rendered.
INVESTIGATION FINDINGS:
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On 5/23/2024 at 11:45 AM, Licensing Program Analysts (LPAs) J. Sampair and A. Gharachorloo arrived unannounced to investigate the allegation above. The LPAs informed Executive Director Evelyn Jensen of the reason for the visit.

The complaint alleges that facility staff did not provide assistance to resident.
Based on a review of facility records, the staff are providing the assistance to resident in accordance with their care plan.

The complaint alleges that facility staff charged resident for services not rendered.
Based on a review of facility records, the facility staff are rendering escorting services the resident pays for that are in accordance with their care plan.

Continues on LIC9099 . . .
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 529-9416
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024
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 2
Control Number 15-AS-20240516085526
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 05/23/2024
NARRATIVE
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. . . Continued from LIC 9099

Although the allegations may have happened, or are valid, there is not a preponderance of evidence to prove them; therefore, the allegations are UNSUBSTANTIATED.

Exit interview conducted with ED. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 529-9416
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2