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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002787
Report Date: 05/10/2021
Date Signed: 05/10/2021 12:56:17 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:CARLTON PLAZA OF SACRAMENTOFACILITY NUMBER:
347002787
ADMINISTRATOR:MANNY DIRARFACILITY TYPE:
740
ADDRESS:1075 FULTON AVENUETELEPHONE:
(916) 971-4800
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:185CENSUS: 117DATE:
05/10/2021
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Andrew StevensonTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Anthony Tuck conducted an office meeting via a phone call with Administrator Assistant Andrew Stevenson and was joined by Licensing Program Manager (LPM) Czarrina Camilon-Lee, Regional Manager (RM) Krystall Moore, and Sacramento County Public Health nurse Ashley Paquia to discuss concerns regarding the ongoing COVID positive cases regarding staff members.

LPA learned that the facility recently had two (2) additional staff members who had tested positive on 05/06/2021 after two (2) staff members recently were cleared. The facility has had an ongoing outbreak since March 2021. During the office visit, it was learned that not all staff have been Fit tested to ensure proper use of N95 masks per Cal OSHA regulations, and not all residents have had response testing completed after it was learned of the two (2) staff members testing positive. The Administrator was reminded that the facility staff should be wearing N95 until outbreak is cleared. A copy of the staffing schedule has been requested from the Administrator to ensure that the facility has adequate staffing. A daily line list has been requested to ensure that all residents and staff are participating in response testing. Facility will ensure that all elements of mitigation plan are being followed.

LPA will contact infection control lead to follow up to ensure that the staff are receiving ongoing training. It was learned that Visitation is currently pre-scheduled at the facility. Per conversation with Sac County Public Health, all visitation shall be stopped until all rounds of response testing are negative, and the facility is cleared. Andrew stated understanding regarding visitation, fit testing, N95 masks, response testing and the line list.

LPA will conduct daily calls to monitor facility COVID status until cleared.

A copy of this report will be sent via email to administrator assistant with a read receipt as part of today's office meeting. Administrator will print, sign and send back the report to LPA.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (209) 242-5200
LICENSING EVALUATOR NAME: Anthony TuckTELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2021
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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