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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200727
Report Date: 11/03/2020
Date Signed: 11/05/2020 04:11:36 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:CARLTON PLAZA OF SAN JOSEFACILITY NUMBER:
435200727
ADMINISTRATOR:JENNELL REVERAFACILITY TYPE:
740
ADDRESS:380 BRANHAM LANETELEPHONE:
(408) 972-1400
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY:183CENSUS: 136DATE:
11/03/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:25 PM
MET WITH:Jennell ReveraTIME COMPLETED:
03:48 PM
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This is an amended report from 11/3/2020 Case Management Visit-Incident to clarify the facility fall risk intervention plan.

Licensing Program Analysts Steve Chang and Joanne Roadilla (LPAs) met with Executive Director Jennell Revera(ED) in order to conduct an unannounced case management tele-visit to review Incident Report about resident fell.

LPAs interviewed ED regarding the incident. Per ED, the incident occurred in the morning resident experienced fall in apartment. The incident happened when R1 and C1 both turned. At that time, R1 lost balance and fell. C1 rushed to help R1.

Incident report stated R1 was sent to the hospital with diagnosis of left arm fracture. The facility updated R1's care plan. Facility added one more caregiver to help R1. Care staff were trained on how to assist R1 with sling. The facility took this incident as a training case to train all staff on how to care for residents who are fall risk. ED stated that the facility will put intervention in place to reduce residents fall risk.

No deficiencies cited during today's tele visit. Exit interview with ED. A copy of this report is emailed to the facility for signature.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2020
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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