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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015600341
Report Date: 06/23/2022
Date Signed: 06/23/2022 11:14:34 AM

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
07/17/2020 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20200717111447
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: 136DATE:
06/23/2022
UNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Nancy Randhawa, Executive DirectorTIME COMPLETED:
11:25 AM
ALLEGATION(S):
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Failure to provide adequate supervision resulting in fracture.
INVESTIGATION FINDINGS:
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On 6/23/2022 at 10:35AM, Licensing Program Analyst (LPA) G. Luk arrived at the facility unannounced to deliver findings on the above allegation. LPA met with Executive Director, Nancy Randhawa and explained the purpose of visit.

On 7/20/2020, LPA Isaac Castro and Licensing Program Manager (LPM) Jeremy Fong initiated 10-day initial investigation via televisit and interviewed Reporting Party (RP). On 7/31/2020, LPA Castro received a video footage of incident. On 8/5/2020, LPA and LPM interviewed Executive Director (ED) Nancy Randhawa. On 6/17/2021, this complaint was reassigned to LPA Luisa Fontanilla.

(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: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022
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 6
Control Number 15-AS-20200717111447
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: 06/23/2022
NARRATIVE
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During the course of investigation, LPA L. Fontanilla did the following:
1. On 3/23/22 interviewed Executive Director
2. On 3/25/22 interviewed Staff 2 (S2)
3. On 3/28/22 interviewed Staff 3 (S3)
4. On 3/22/22, reviewed video footage of incident, needs and services plan, admission agreement, Physician’s Report

Based on interviews conducted with S2 and S3, they confirmed with LPA that they were working night shift on 6/19/2020. One is assigned to stay in the hallway to redirect residents and one stays with resident in the TV room. S2 is the assigned caregiver to stay with R1 in the TV room when the incident happened. S2 and S3 confirmed with LPA that R1 was already in the TV room when they started the shift. Both S2 and S3 state that R1 is ambulatory but they would always escort R1 in going to the restroom because R1 is unsteady.

S2 confirmed with LPA that S2 was in the same room with R1 during the incident but did not notice R1 get up and walk. S2 states S2 was sitting facing the wall. When LPA asked S2 the reason for facing the wall, S2 states “I don’t know why I was facing the wall.”

A review of R1’s Personal Service Plan Assessment dated 06-20-2020 indicates R1 needs transfer assistance requiring 1 caregiver if needed with:

1. Dressing/Undressing (AM and PM)

2. Bathing

3. Toileting

The Service Plan also indicates staff will conduct periodic checks on R1 at bedtime when resident is sleeping in the room. And that R1 needs to be monitored for balance and safety.

A review of the video footage from the incident shows R1 sleeping on the chair in the TV room.

(Continue on LIC9099C...)

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 15-AS-20200717111447
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: 06/23/2022
NARRATIVE
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R1 woke up, looked around, pushed then pulled chair in front and tried to get up from the chair. R1 stood up and started walking but looked unsteady. R1 used chairs for support while walking towards the counter. When R1 was close to the counter, R1 lost balance, fell backwards with the chair on top of her. S2 came followed by S3.

A review of R1’s medical records indicate R1 sustained closed displaced fracture of right femoral neck. R1 underwent right hip hemiarthroplasty.

Based on interviews, video footage and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Sec. 1569.269(a)(10) and Sec. are being cited on the attached LIC 9099D.


A $500.00 immediate civil penalty is assessed on this day. Civil penalty determination related to serious bodily injury is pending.

Exit interview was conducted. A copy of this report, appeal rights, and civil penalty were provided to Executive Director, Nancy Randhawa.

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 15-AS-20200717111447
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: 06/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
06/24/2022
Section Cited
HSC
1569.269(a)(10)
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Enumerated rights; severability.
To be free from neglect,..., intimidation, and verbal, mental, physical, or sexual abuse.
This This requirement is not met as evidenced by:
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By POC date, Executive Director will conduct training with all staff of Sec. 1569.269 Enumerated Rights
and submit proof of training and sign in sheet to CCL.
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Based on interviews conducted, records and video footage reviewed, on 6/20/2020 facility staff failed to assist R1 when R1 woke up, got up from the chair and walked which resulted to R1 falling and sustained fracture of right femoral neck. R1 underwent right hip hemiarthroplasty and has moved out of the facility.
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A Non-Compliance Conference (NCC) will be scheduled.
A $500.00 immediate civil penalty is assessed on this day. Civil penalty determination related to serious bodily injury is pending.
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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: 06/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
07/17/2020 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20200717111447

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: 136DATE:
06/23/2022
UNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Nancy Randhawa, Executive DirectorTIME COMPLETED:
11:25 AM
ALLEGATION(S):
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Resident is being over charged for services not received.
Failure to safeguard resident's personal belongings.
Failure to provide appropriate sleeping arrangement.
INVESTIGATION FINDINGS:
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On 6/23/2022 at 9:30AM, Licensing Program Analyst (LPA) G. Luk arrived at the facility unannounced to deliver findings on the above allegations. LPA met with Executive Director, Nancy Randhawa and explained the purpose of visit.

Resident is being over charged for services not received.
On 3/22/2022, LPA L. Fontanilla obtained and reviewed R1’s Personal Assessment Plan. On3/23/2022, LPA L. Fontanilla interviewed ED. ED states that R1 was moved from assisted living to memory care unit on 6/19/2020 due to changes in behavior. ED states R1 is ambulatory and never had a fall while in the assisted living. On 3/22/2022, LPA sent an email to RP requesting for additional information. However, RP has not responded to LPA’s request as of this time. LPA is unable to identify what service was not provided to R1. This allegation is unsubstantiated.
(Continue on LIC9099C...)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 15-AS-20200717111447
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: 06/23/2022
NARRATIVE
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Failure to provide appropriate sleeping arrangement.

Failure to safeguard resident's personal belongings.

On 3/25/22, LPA L. Fontanilla interviewed S2 and on 3/28/22, LPA interviewed S3. Staff interviewed confirmed with LPA that R1’s bed and personal belongings were in R1’s room when R1 was moved to the Memory Care Unit. Records reviewed indicate that on 6/19/2020, R1’s family was informed that all of R1’s belongings were moved to R1’s room in the Memory Care Unit.

When interviewed by LPA on 3/25/2022, S2 states at the start of shift, R1 was already in the TV room sleeping. Staff from the previous shift told S2 that R1 refused to sleep in the room. S3 states they asked R1 to sleep in the room but R1 refused.

Based on interviews conducted and records reviewed, the above allegations are unsubstantiated.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.



There is no deficiency noted.

Exit interview was conducted and a copy of this report was provided to Executive Director, Nancy Randhawa.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6