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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015600341
Report Date: 05/05/2023
Date Signed: 05/05/2023 05:47:23 PM

Substantiated


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
05/27/2022 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20220527105302
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: 85DATE:
05/05/2023
UNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Lorina Hernandez, Dining Room Manager
Kushir Kuar, Memory Care Director		TIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Facility is not following COVID-19 protocols.
INVESTIGATION FINDINGS:
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On 5/5/2023 at 4:30PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegation above. LPA met with Lorina Hernandez, Dining Room Manager and Kushir Kuar, Memory Care Director.

During the course of investigation, LPA interviewed 6 staff. LPA reviewed and obtained documents (mitigation plan, staff schedule, physician's report, emergency information, care notes, care plan, family email correspondence, and CCLD PINs).

Care notes on 5/11/2022 stated that R1 was having congestion and a runny nose. PCP stated, "check rapid COVID test..." However, R1 was not tested for COVID-19 until 5/14/2022. Email correspondence with R1's family states that facility was not authorized to administer COVID test and asked R1's family to make arrangements. (Continue on LIC9099C...)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023
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 3
Control Number 15-AS-20220527105302
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: 05/05/2023
NARRATIVE
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Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20220527105302
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
05/15/2023
Section Cited
CCR
87405(d)(2)
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Administrator - Qualifications and Duties. Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement is not met as evidence by:
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Facility has agreed to submit a written plan regarding reviewing CCLD PINs and submit the written plan to CCLD by POC date.
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Based on investigation, licensee did not comply with the section cited above by not testing resident with symptoms which poses a potential health and safety risk to the 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) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3