435200727-9-12-2024-26-AS-CCHG-D9325U-20240912170608

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435200727
Report Date: 09/12/2024
Date Signed: 09/12/2024 05:06:19 PM

Document Has Been Signed on 09/12/2024 05:06 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
CENTRAL COAST CR/RES, 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: 94	DATE:	09/12/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Shantela Yadao		TIME COMPLETED:	01:29 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) Steve Chang conducted an unannounced annual inspection visit and met with Executive Director (ED) Shantela Yadao. LPA reviewed 5 resident files and 5 staff files. LPA toured the facility inside and out with ED. LPA observed license, ADM Certificate, and personal rights posters in the facility. LPA toured the first floor. LPA inspected the lobby, living room, common restrooms, dining room, kitchen, laundry room, and resident rooms. LPA toured the second floor. LPA inspected the activity rooms, chemical storage room, nurse room, salon room and resident room. LPA toured the third floor. LPA inspected activity room, game room, laundry room, and resident rooms. The facility has a incident at 3:00AM today. The faucet of room 327 was broken. The water came out, room #327, #329, #330, #328, nurse office in the second floor and room #115 at the first floor are affected. The facility fixed the issue this morning. The affected rooms are got dried. LPA checked all the affected rooms, and they are without problems. The affected rooms are waiting to dry. ED stated they should be fine and recover back to normal around noon time today. The room temperature of the facility was at 72 degree F. The temperature of the refrigerator was observed at 40 degree F, and the temperature of the freezer was at 0 degree F. Hot water was measured at 106 degree F. Medication room and medication carts were observed locked. Chemical rooms was observed locked. Knives closet was observed locked. Continue on LIC809-C. Page 1 of 2.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: CARLTON PLAZA OF SAN JOSE	FACILITY NUMBER: 435200727
	VISIT DATE: 09/12/2024

NARRATIVE

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Fire extinguisher was serviced on 08/15/2024. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Fire alarm system was tested and was working fine. Carbon monoxide detector was observed running out of battery, the facility fixed it before LPA finished the inspection. LPA tested the door delay opening for the memory care unit and it was working fine. The memory care unit backyard and assisted living unit back yard were inspected. Both have the delay opening gates.

Deficiencies noted today. See LIC809-D An exit interview was conducted with ED. This report was provided to ED to review. A copy of this report was provided to ED.

Page 2 of 2.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 09/12/2024 05:06 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: CARLTON PLAZA OF SAN JOSE	FACILITY NUMBER: 435200727
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)(11)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in that 2 out of 5 staff files were observed without health screen form which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/19/2024
	Plan of Correction
1 2 3 4	Executive Director stated to submit a plan of correction by the POC due date to have staff with valid health screen form.

Type B

Section Cited

CCR

87465(h)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in that 1 out 5 resident files was observed the centrally stored medications form inaccurate and not maintained up to date which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/19/2024
	Plan of Correction
1 2 3 4	Executive Director stated to submit a plan of correction by the POC due date to maintain resident centrally stored medication form accurate and up to date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3