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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200727
Report Date: 05/10/2024
Date Signed: 05/11/2024 01:26:44 PM


Document Has Been Signed on 05/11/2024 01:26 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 JOSEFACILITY NUMBER:
435200727
ADMINISTRATOR:SHANTELA YADAOFACILITY TYPE:
740
ADDRESS:380 BRANHAM LANETELEPHONE:
(408) 972-1400
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY:183CENSUS: 138DATE:
05/10/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
05:10 PM
MET WITH:Shantela YadaoTIME COMPLETED:
06:30 PM
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Licensing Program Analysts (LPAs) Steve Chang and Manuel Monter conducted an unannounced case management- incident visit and met with Executive Director (ED) Shantela Yadao.

On 5/10/24, the Department received an incident report from the facility that on 5/7/24 at noon, the facility fire alarm and fire sprinkler system was activated in the AL unit on the 3rd floor. Fire Department (FD) responded upon activation of fire alarm in the facility. FD determined that R1 was burning a paper and it got out of control. No major fire damage reported other than R1's door frame in the bathroom and walls were black due to smoke. R1's apartments next door as well as below on 2nd and 1st floor were all affected as water leaked below and hallways. All residents were having lunch when the incident happened. All residents including R1 were evacuated out of the facility safely. No injuries and/or hospitalization reported. No known media attention.

LPAs toured the affected rooms 121B, 251, 334, 337 and 339. The rooms were used fan to dry out the water. ED stated the rooms will be back to normal on 5/13/24 Monday. LPAs interviewed resident R1. R1 denied he/she made the fire. R1 stated he/she did not know what happened.

ED stated the facility took R1's lighters and update R1's care plan. LPAs requested R1's physician report, Appraisal Needs and Service Plan. ED stated no one got injury. ED stated the facility will update CCL office.

ED stated he/she will send follow up action plan to LPA.

Exit interview was conducted with ED. The report was provided to ED for signature.

SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2024
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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