435200727-10-31-2024-26-AS-KHOS-DAXPNG-20241112102754

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435200727
Report Date: 10/31/2024
Date Signed: 10/31/2024 04:49:51 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/21/2024 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20240521084801

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: 93	DATE:	10/31/2024
		UNANNOUNCED	TIME BEGAN:	11:50 AM
MET WITH:	Shantela Yadao		TIME COMPLETED:	12:50 PM

ALLEGATION(S):

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The facts provided in the 30 day eviction notice for a resident is without foundation or merit.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation finding and met with Executive DIrector (ED) Shantela Yadao.

On 5/21/2024, the Department received a complaint with the allegation that the fact provided in the 30 day eviction notice for a resident is without foundation or merit.

On 5/30/2024, the Department conducted an initial investigation visit.

LPA interviewed ED, 5 staff (S1 - S5), and resident R1.

LPA requested resident file documents including progress notes, appraisal needs and service plan.

Continue on LIC9099-C. page 1 of 3.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024

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

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 26-AS-20240521084801

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/31/2024

NARRATIVE

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The facts provided in the 30 day eviction notice for a resident is without foundation or merit:
The allegation is that resident R1 denied the accusation specified on the 30 days eviction letter issued by the facility .

Resident R1 was accused that on 4/18/2024, R1 made an inappropriate comment stating to push facility staff out of the window and pulled an Swiss knife out and pretended to stab facility staff.

Resident R1 was accused on 5/7/2024, around 12:30PM, R1 lit something on fire in R1's bathroom, creating a large fire to set off the facility sprinkler system which resulted in serious water damage to the facility. The fire threatened the health and safety to the residents and staff at the facility.

On 5/30/2024, LPA interviewed staff S1. S1 stated on 4/18/2024, he/she and staff S2 went to R1's room to fix R1's internet problem. S1 stated R1 stated “I wonder what would happen if you would fall from the window”. S1 stated R1 took out an Swiss army knife and took off the knife part of the Swiss army knife.

LPA interviewed staff S2. S2 stated he/she went with S1 to fix R1's internet problem. S2 stated he/she heard R1 stated something about throwing something over the window. S2 stated R1 had a little knife, and then gestured his knife close to S1. S2 stated the knife was too close to S1.

Based on the review of the incident report dated 5/9/2024, on 5/7/2024 around noon time, the facility fire alarm was activated. The fire panel indicated the source from room #337 of resident R1. Water was pouring out, flowing to the hallway. Fire fighters came in the facility and stated that it seems as if R1 was burning paper and got out of control and sprinkler was activated. Resident rooms next door as well as below on second floor and first floor were all affected as water leaked below.

On 5/10/2024, LPA toured the facility. LPA observed R1's room #337 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. LPA toured the affected rooms 121B, 251, 334, 337 and 339. The rooms were used fans to dry out the water.

Continue on LIC9099-C. Page 2 of 3.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20240521084801

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/31/2024

NARRATIVE

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LPA interviewed Executive Director (ED). ED stated ED stated the facility took R1's lighters after the incident.

On 5/20/24, the facility issued a 30 day eviction letter to R1 based on public safety concern of the incident occurred on 5/7/2024.

On 5/30/2024, LPA interviewed staff S3 and S4. Both stated when they went to the third floor and entered R1's bedroom on 5/7/2024, they saw there was smoke in R1’s kitchen.

LPA interviewed staff S5. S5 stated on 5/7/2024 he/she entered R1's room, and he/she did see some smoke and some char debris in the water.

On 6/14/2024, LPA received an email from ED with a recording of voicemail that declaring no longer wants to pursue the complaint.

On 6/27/2024, R1 moved out from the facility with R1's family member agreement.

Based on the review of the fire fighter report dated 5/7/2024, the sprinkler was activated by room #337, and the water damage was observed to the rooms in the third floor, second floor and first floor.

R1 did not comply with general policies of the facility that resident must not engage in conduct that poses a danger to self or others at the facility, must not be disruptive, must not create unsafe condition.

The Department has investigated the above allegations. Based on the investigation, records reviewed, observation, and interviews conducted, the Department found that the above allegation is UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis.

No citations noted at today’s compliant investigation visit. Exit interview conducted with Executive Director (ED). This report was provided to review and for signature. A copy of this report was provided to ED.

Page 3 of 3.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 3