015600341-3-30-2023-15-AS-KHOS-CQYR2V-20230417123854

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015600341
Report Date: 03/30/2023
Date Signed: 03/30/2023 02:48:37 PM

Unfounded

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
10/14/2022 and conducted by Evaluator Gregory Clark

COMPLAINT CONTROL NUMBER: 15-AS-20221014155616

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: 142	DATE:	03/30/2023
		UNANNOUNCED	TIME BEGAN:	02:25 PM
MET WITH:	Nancy Randhawa, Executive Director		TIME COMPLETED:	02:55 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility is not allowing resident to have visitors
Resident's phone is in disrepair
Facility falsified resident's diagnosis upon admission

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 3/30/23 at 2:25 p.m. Licensing Program Analyst (LPA) Greg Clark conducted an unannounced visit to deliver the findings for the above allegations. LPA met with Nancy Randhawa, Executive Director and explained the purpose of the visit.

During the course of the investigation on 10/24/22 LPA L. Hall interviewed 2 staff (S1 & S2), resident #1 (R1) and witnesses 1, 2 and 3 (W1, W2, W3). LPA G. Clark reviewed R1’s records including physician's report, individual service plan and admission agreement.

Facility is not allowing resident to have visitors
On 10/18/22 LPA spoke with Reporting Party (RP). RP confirmed that she is not being allowed to visit R1.
On 10/24/22 LPA L. Hall interviewed S1. S1 stated that the RP is on R1’s exclusion list and that she is not allowed to visit R1 per W1. LPA G. Clark reviewed R1’s Durable Power of Attorney dated 4/25/2019 and found that W1 has the right to limit visitors.

***report continues on LIC9099C***

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory Clark	TELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023

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 2

Control Number 15-AS-20221014155616

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: 03/30/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Resident's phone is in disrepair

LPA observed while at the facility on 3/30/23 that the facility has a working telephone for the resident’s use. This meets Title 22 regulation #80073.

Facility falsified resident's diagnosis upon admission

LPA G. Clark reviewed R1’s admission agreement dated 9/28/22, individual service plan dated 10/19/22 and physician’s report dated 9/23/22. LPA L. Hall interviewed S2 on 10/24/22. LPAs did not find any discrepancies among the reports and the staff interview regarding R1’s diagnosis.

This agency has investigated the complaints alleging facility is not allowing resident to have visitors, resident's phone is in disrepair and facility falsified resident's diagnosis upon admission. We have found that the complaints were UNFOUNDED, meaning that the allegations were false, could not have happened and/or is without a reasonable basis.

Exit interview conducted, a copy of this report provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory Clark	TELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2