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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002805
Report Date: 11/04/2021
Date Signed: 11/04/2021 11:24:46 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:CARLTON SENIOR LIVING ORANGEVALEFACILITY NUMBER:
345002805
ADMINISTRATOR:SCHUMANN, LISAFACILITY TYPE:
740
ADDRESS:8773 OAK RDTELEPHONE:
(925) 370-6220
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:136CENSUS: 54DATE:
11/04/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:28 AM
MET WITH:Lisa Schumann, Executive DirectorTIME COMPLETED:
12:00 PM
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On November 4, 2021, at 10:30am, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to conduct a Pre-licensing Inspection. LPA met with Lisa Schumann, Executive Director and explained purpose of the inspection. Prior to initiating the inspection LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and a mask was worn for Personal Protective Equipment (PPE). The facility is a single floor facility with a capacity of 136.

LPA observed the following:
Administrator certificate is valid, expiring 3/27/2023. First aid kit fully stocked and ready for emergency use. Fire extinguishers fully charged. Common areas were clean and in good repair. Bedrooms had required furniture and lighting. Facility has required (2) day perishable supply of food and (7) supply of non-perishable food. Medication was properly stored and locked away.

At the time of this inspection, the facility is in compliance and meets the minimum requirements for Residential Care Facility for the Elderly.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations were observed during this visit.

Application is pending further review.

Exit interview conducted and a copy of this report given to Lisa Schumann

SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-LyonsTELEPHONE: (916) 212-3983
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.
LIC809 (FAS) - (06/04)
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