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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 05:44:20 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
05/13/2022 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20220513143422
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:
02:50 PM
MET WITH:Lorina Hernandez, Dining Room Manager
Kushir Kuar, Memory Care Director		TIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Facility does not follow COVID-19 protocol
Staff did not notify responsible party of resident's change in condition
Staff did not distribute resident's self administered medication as prescribed
INVESTIGATION FINDINGS:
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On 5/5/2023 at 2:50PM, 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 Lorina Hernandez, Dining Room Manager and Kushir Kuar, Memory Care Director.

During the course of investigation, LPA interviewed 5 staff and complainant. LPA reviewed and obtained documents (staff schedule, COVID-19 test results, physician's report, medication list, emergency information, care plan, care notes, MAR, mitigation plan, and CCLD PINs).

Facility does not follow COVID-19 protocol
Care notes on 4/29/2022 stated that R1 was coughing and not feeling well. However, R1 was not tested for COVID-19 until 5/4/2022. Interview with staff indicated that facility was unable to conduct or provide COVID-19 antigen test kit to test R1. (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 6
Control Number 15-AS-20220513143422
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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Staff did not notify responsible party of resident's change in condition
Interview with staff revealed that managers or nurses would contact responsible party if resident has changes in condition and would be documented in the care notes. LPA observed care notes on 4/29/2022 states that R1 was coughing and not feeling well. Care notes on 4/29/2022 and 4/30/2022 did not indicate that responsible party was notified that R1 wasn't feeling well and coughing.

Staff did not distribute resident's self administered medication as prescribed
Care notes on 4/30/2022 at 5:28PM states that R1's family gave Med Tech some meds for R1 if needed. R1's April 2022 MAR indicates that Robitussin DM was entered at 4/30/2022 at 7:21PM and care notes revealed that R1 has a very strong cough since 4/30/2022 at 6:15AM. However, Robitussin was not administered to R1 until 5/1/2022.

Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegations are 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 6
Control Number 15-AS-20220513143422
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 A
05/08/2023
Section Cited
CCR
87465(c)(2)
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Incidental Medical and Dental Care. Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidence by:
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Facility has agreed to conduct training for staff that administer medications and submit staff sign-in sheet and training materials to CCLD by POC date.
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Based on investigation, licensee did not comply with the section cited above by not administering PRN medication which poses an immediate health and safety risk to the persons in care.
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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 6
Control Number 15-AS-20220513143422
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
87468.1(a)(8)
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Personal Rights of Residents in All Facilities. To have their representatives regularly informed by the licensee of activities related to care or services... This requirement is not met as evidence by:
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Facility has agreed to conduct training on notifying resident's representatives and submit staff sign-in sheet and materials to CCLD by POC date.
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Based on investigation, licensee did not comply with the section cited above by not notifying R1's family when R1 had a change in condition 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: 4 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
05/13/2022 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20220513143422

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:
02:50 PM
MET WITH:Lorina Hernandez, Dining Room Manager
Kushir Kuar, Memory Care Director		TIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not assist resident with obtaining medical care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 5/5/2023 at 2:50PM, 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 5 staff and complainant. LPA reviewed and obtained documents (staff schedule, COVID-19 test results, physician's report, medication list, emergency information, care plan, care notes, MAR, mitigation plan, and CCLD PINs).

Interview with staff revealed that R1's family was present at the facility on 4/30/2022 and obtained doctor's order for R1's cough medicine. Care notes on 4/29/2022 states "R1 was coughing and doesn't feel well. Took her vitals and was ok." (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: 05/05/2023
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: 5 of 6
Control Number 15-AS-20220513143422
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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Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore these allegation is 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: 05/05/2023
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: 6 of 6