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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200727
Report Date: 09/13/2022
Date Signed: 09/14/2022 08:29:54 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/14/2022 08:29 AM - 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 JOSEFACILITY NUMBER:
435200727
ADMINISTRATOR:SHANTELA YADAOFACILITY TYPE:
740
ADDRESS:380 BRANHAM LANETELEPHONE:
(408) 972-1400
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY:183CENSUS: 90DATE:
09/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Shantela YadaoTIME COMPLETED:
11:59 AM
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Licensing Program Analysts (LPAs) Steve Chang and Simi Rai arrived at the facility. Upon arrival, the front desk staff conducted an infection control/prevention screening, and body temperature check, then logged LPA in visitor logs.

LPA met with Executive Director (ED) Shantela Yadao. LPA addressed the purpose of today's visit to ED.

LPA toured the facility inside out with ED. LPA inspected the dinning room of Assisted Living Unit and activity rooms and TV room. LPA inspected the resident apartment rooms of Assisted Living Unit. LPA inspected the dinning room and resident apartment rooms in Memory Care Unit. The beds in the shared rooms were observed 6 feet apart. The public restrooms. Salon room, mailbox room, kitchen, and laundry room were inspected. The backyard of Assisted Living Unit and backyard of Memory Care Unit were inspected. Some trash cans were observed without covers, ED stated ED will put all the trash cans with covers in 3 days. Some of the sinks in the restrooms were observed without the posters of washing hands for 20 seconds. ED stated ED will put the posters of washing hands for 20 seconds on for all the restrooms in 3 days. PPE supplies were observed sufficient. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Fire extinguisher was serviced on 09/08/2022. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors were tested by ED, and were working fine. Backyard was inspected. There was no obstruction to block the walkways.

LPA observed the exits and elevators have the hand sanitizers. LPA observed all the staff wore the masks.

Continuation see LIC809-C
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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
VISIT DATE: 09/13/2022
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The facility already submitted the Infection Control Plan to LPA.

No citation was issued for today's inspection. An exit interview was conducted with ED. This report was provided to ED to review. A copy of this report was provided to ED.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022
LIC809 (FAS) - (06/04)
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