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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600341
Report Date: 10/07/2024
Date Signed: 10/07/2024 04:43:34 PM


Document Has Been Signed on 10/07/2024 04:43 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: 157DATE:
10/07/2024
TYPE OF VISIT:Case Management - DeficienciesANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Administrator Evelyn JensenTIME COMPLETED:
05:00 PM
NARRATIVE
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On 10/7/2024 at 3:00 PM, Licensing Program Analysts (LPAs) James Sampair and David Doidge conducted a Case Management - Deficiencies inspection. Upon entry into facility, the LPAs explained the purpose of the visit to Administrator Evelyn Jensen.

This visit was prompted by the Licensee's failure to reduce the number of non-ambulatory residents living on the third floor of the facility to 6 in accordance with the fire clearance.

The facility was cited for this infraction.

Exit interview conducted with Administrator. A copy of this report and the appeal rights were provided to the Administrator.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 529-9416
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2024
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 10/07/2024 04:43 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: 10/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/14/2024
Section Cited
CCR
87204(a)

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87204 Limitations - Capacity and Ambulatory Status (a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license . . .

This requirement is not met as evidenced by:
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On or before the due date, the Licensee shall reduce the number of non-ambulatory residents living on the third floor from 12 to 6 and inform the Department of the reduction.
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Based on observation, the Licensee did not comply with the section cited above as 12 and not 6 non-ambulatory residents are living on the third floor of the facility, 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.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 529-9416
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2024
LIC809 (FAS) - (06/04)
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