015600341-11-4-2021-15-AS-KHOS-C9CPCU-20211203101230

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015600341
Report Date: 11/04/2021
Date Signed: 11/04/2021 02:53:25 PM

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
12/03/2020 and conducted by Evaluator Leslie Ibo

COMPLAINT CONTROL NUMBER: 15-AS-20201203103039

FACILITY NAME:	CARLTON PLAZA OF SAN LEANDRO		FACILITY NUMBER:	015600341
ADMINISTRATOR:	NANCY RANDHAWA		FACILITY TYPE:	740
ADDRESS:	1000 EAST 14TH ST.		TELEPHONE:	(510) 636-0660
CITY:	SAN LEANDRO	STATE: CA	ZIP CODE:	94577
CAPACITY:	199	CENSUS: 144	DATE:	11/04/2021
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Jocelynn Ahnstrom		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Facility door(s) is in disrepair
Staff not ensuring water temperature was appropriate for residents

INVESTIGATION FINDINGS:

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On 11/4/2021, Licensing Program Analyst (LPA), L. Ibo arrived unannounced to conduct an to deliver complaint findings for the above allegations. LPA met with Jocelyn A. and explained the reason for the visit. Administrator is not available during the visit, Administrator gave permission to LPA to give copy of report to Jocelynn. This complaint is from December 2020 and primary investigation was completed by another LPA Praveen Singh, complaint was re-assigned to LPA L. Ibo.

During the course of investigation, LPA L. Ibo toured the facility’s common area such as but not limited to, dining area, courtyard and memory care unit. LPA checked water temperature for random rooms; room #113 has water temperature of 105.3 degrees Fahrenheit, room #110’s water temperature has 107.3 degrees Fahrenheit & room #111 has water temperature of 107.9 degrees Fahrenheit.

...Continued from LIC9099...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20201203103039

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: 11/04/2021

NARRATIVE

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LPA observed that facility door #4 is equipped with delayed egress that is required for memory care unit, the door has an alarm with door sign stating “keep pushing door will open in 15 seconds alarm will sound” , this was observed with both doors number 4 & 5. Both doors are functional during the visit. LPA conducted interview with S4 & S3, according to S4 & S3, both doors #4 & #5 gets testing (delayed egress) every week as part of physical plant maintenance, a copy of maintenance check was obtained. S3 do not recall any malfunctions on both doors back in December 2020.

Based upon 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.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021

LIC9099 (FAS) - (06/04)

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