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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
435200727
Report Date:
05/30/2024
Date Signed:
05/30/2024 04:41:25 PM
Document Has Been Signed on
05/30/2024 04:41 PM
- It Cannot Be Edited
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 JOSE
FACILITY NUMBER:
435200727
ADMINISTRATOR:
SHANTELA YADAO
FACILITY TYPE:
740
ADDRESS:
380 BRANHAM LANE
TELEPHONE:
(408) 972-1400
CITY:
SAN JOSE
STATE:
CA
ZIP CODE:
95136
CAPACITY:
183
CENSUS:
145
DATE:
05/30/2024
TYPE OF VISIT:
Case Management - Incident
UNANNOUNCED
TIME BEGAN:
02:47 PM
MET WITH:
Yoliana Sanchez
TIME COMPLETED:
04:40 PM
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Licensing Program Analysts Steve Chang and Manuel Monter conducted an unannounced case management and met with
Executive Assistant Yoliana Sanchez (EA). The purpose of today's visit was to open a complaint and get additional information regarding an incident report.
LPAs interviewed EA and staff S1. EA provided LPA's with the police report case number.
Both EA and S1 stated resident R1 was normal as usual. EA stated R1 was in hospice care before and graduated from hospice care in January 2024.
EA stated staff S2 found R1 unresponsive in R1's bedroom. The facility called 911. Paramedics came in the facility and the police officers arrived also.
LPAs requested R1's physician report and appraisal needs and service plan.
Exit interview was conducted with EA. No deficiencies cited during today's visit.
The report was provided to EA for signature. A copy of the report was provided to EA.
SUPERVISOR'S NAME:
Romeo Manzano
TELEPHONE:
(408) 324-2112
LICENSING EVALUATOR NAME:
Chihhsien Chang
TELEPHONE:
(408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE:
05/30/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/30/2024
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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