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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015600341
Report Date: 05/16/2023
Date Signed: 05/16/2023 04:02:10 PM

Unsubstantiated


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
01/07/2022 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20220107131813
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: 135DATE:
05/16/2023
UNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Nancy Randhawa, Executive DirectorTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Facility gave resident the wrong amount of a medication.
Resident was not allowed to manage their own medication.
INVESTIGATION FINDINGS:
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On 5/16/2023 at 12:40PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegations above. LPA met with Executive Director, Nancy Randhawa.

During the course of investigation, LPA interviewed 5 staff. LPA reviewed and obtained documents (physician's report, care plan, medication list, medication orders, and MAR).

Facility gave resident the wrong amount of a medication.
Interview with staff revealed there were no errors that occurred with R1's medication. LPA observed prescription for Memantine was ordered on 10/25/2021 and a change in order for the same medication was received on 10/27/2021. Medication was discontinued on 11/17/2021. LPA observed R1's MAR and medications were given per doctor's order. (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: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
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-20220107131813
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: 05/16/2023
NARRATIVE
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Resident was not allowed to manage their own medication.
Interview with staff revealed that if a resident's medical assessment indicates that they cannot handle medications, then the resident would automatically be enrolled in the facility's medication program. LPA reviewed R1's medical assessment dated 3/16/2021 which states that R1 is not able to administer own prescription medication.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore these allegations are UNSUBSTANTIATED.

No deficiencies are being cited on this date.

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

DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2