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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435200727
Report Date: 08/05/2025
Date Signed: 08/06/2025 08:02:34 AM

Substantiated


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
08/12/2024 and conducted by Evaluator Chihhsien Chang
COMPLAINT CONTROL NUMBER: 26-AS-20240812112833
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: 95DATE:
08/05/2025
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Shantela YadaoTIME COMPLETED:
01:50 PM
ALLEGATION(S):
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Neglect/lack of supervision resulted in resident on resident altercation.
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 8/12/2024, the department received a complaint regarding two residents (R1 and R2) having physical altercation in the memory care unit.

On 8/21/2024, the Department conducted an initial investigation visit, conducted interviews with Executive Director, 3 staff (S1 - S3), two private caregivers (PC1, PC2), and residents (R1, R2), and requested copies of documents such as but not limited to physician’s report, appraisal needs and services plan, updated care plan and incident reports.

Continue on LIC9099-C. Page 1 of 4.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025
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 5
Control Number 26-AS-20240812112833
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: 08/05/2025
NARRATIVE
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On 8/21/2024, LPA interviewed executive Director (ED) Shantela Yadao. ED stated that on 8/3/2024, around 7:30AM, residents R1 and R2 were at the hallway of memory care unit. R1 grabbed R2's shirt when R2 tried to pass R1. R2 told R1 "leave me alone". R1 did not stop grabbing R1's shirt and R2 pushed R1 away which resulted in R1 falling to the ground.

ED stated there were 3 caregivers (S1, S2, S4) helping residents in memory care unit at that time, and 1 LVN (S3) was on duty responsible for memory care unit at that time. ED stated caregivers rushed on site when heard the noise. The facility staff S1 called 911 immediately and R1 was sent to ER hospital due to head injury. R1 was discharged from hospital and returned to the facility at 2:30PM on the same day.

ADM stated R1 and R2 live in the memory care unit of the facility, and each one has a one-on-one companion and both companions start at 8:00 AM.

On 8/21/2024, LPA interviewed caregiver S1. S1 stated on 8/3/2024, around 7:30AM, he/she was assisting resident in room #125 and heard R2 in loud voice stating "Leave me alone ... don't touch me" . S1 stated he/she rushed out of room #125 to on site in the hallway across room #125 of the incident, he/she saw R1 was pulling R2's shirt and R2 pushed R1 away, who landed on his/her bottom to the floor and hit the head.

S1 stated the altercation between R1 and R2 happened very quickly he/she tried to intervene, but it was too late. S1 stated caregivers S2 and S4 were assisting other residents in memory care unit. S1 stated caregiver S2 came to assist R1 with him/her to let R1 to sit on chair. S1 stated he/she called 911 and LVN due to R1 was bleeding on the head. S1 stated ambulance came and R1 was sent to hospital due to head injury.

On 8/21/2024, LPA interviewed caregiver S2. S2 stated on 8/3/2024, around 7:30AM, he/she was assisting residents when he/she heard S1 screaming "Don't do that". S2 stated he/she paused assisting resident and rushed outside resident room to see what was going on. S2 saw R1 was on the floor with head bleeding. S2 stated S1 called 911 and LVN. R1 was sent to hospital due to head injury.

On 8/21/2025, LPA interviewed LVN (referred as S3), who stated that on 8/3/2025, around 7:30AM, he/she received a phone call from S1. S3 stated S1 reported the incident of R1 and stating S1 already called 911. S3 stated police officers and ambulance came in around 5 minutes after he/she received the phone call from S1. S3 stated R1 was sent to hospital due to R1's head injury.

Continue on LIC9099-C. Page 2 of 4.

SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 26-AS-20240812112833
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: 08/05/2025
NARRATIVE
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On 8/21/2024, LPA attempted to interview R1 at R1's room. R1 did not respond to LPA's questions regarding to the incident due to cognitive disorder. LPA observed that R1 was combative, refused and resisted assistance from staff S2 and his/her private companion (PC1). LPA interviewed R1's private companion (PC1) in R1's room, who stated R1 is combative with staff who are assisting R1 with his/her ADLs. PC1 stated R1 likes to go around grabbing things with his/her hand but has no cognition of what he/she is doing because of cognitive disorder.

On 8/21/2024, LPA attempted to interview R2. R2 was unable to answer LPA's questions regarding the incident. LPA observed R2 was not combative and was compliant with staff and his/her private companion's (referred to as PC2) assistant. LPA interviewed PC2 who stated R2 is usually calm and friendly, and has no problem when being assisted with his/her ADLs.

ADM stated on 8/3/2025, facility staff notified R1 and R2s' responsible parties of the incident. ADM stated a care conference was scheduled to discuss and develop a plan to prevent R1 and R2's engaging in future physical altercations and reached to an agreement that to provide a 24/7 private caregiver for R1 and a private caregiver from 7:00AM to 8:00PM every day for R2, and possible relocation plans for R1 and R2.

Based on the review of the incident report dated 8/5/2024. On 8/3/2024, around 7:30AM, R1 and R2 were walking in the hallway of memory care unit and R1 grabbed R2. R2 pushed R1 away and R1 fell on the floor. Staff S1 came on site to assist R1, and S2 and S4 also came to assist R1 to sit on chair. R1 was sent to hospital due to injury.

Based on the interview and documents reviewed including but not limited to incident reports, prior to this incident on 8/3/2024, there were 2 incidents occurred between R1 and R2 with similar scenarios on 6/4/2024 and 6/8/2024. On 6/4/2024, around 7:29AM, at the hallway in memory care unit, R1 and R2 were walking at the hallway of the memory care unit and R1 blocked R2. R2 tried to walk around but R1 grabbed R2. R2 pushed R1 away and R1 fell on the ground. R1 sustained laceration on the head and was sent to hospital. On 6/8/2024, around 11:15AM, at the dinning area of memory care unit, R1 slapped at R2 and R2 pushed R1 away. R1 fell down and hit the head. R1 sustained bleeding on the head and was sent to hospital.


Continue on LIC9099-C. Page 3 of 4.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 26-AS-20240812112833
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/06/2025
Section Cited
CCR
87464(F)(1)
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87464 Basic Services(f) Basic services shall at a minimum include:(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code
section 1569.2(c).

This requirement is not met as evidenced by:
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Executive Director (ED) stated to submit a plan of correction by the POC due date and provide staff training to prevent the similar incidents to happen again. ED agreed to send the staff training log to CCL office.
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Based on interview and record reviewed, The facility did not provide the necessary care and supervision to resident R1 and R2 to meet R1 and R2's care needs and leading to R1's multiple falls and sustained head injury which poses/posed an immediate Health, Safety risk to persons in care.
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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 ManzanoTELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 26-AS-20240812112833
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: 08/05/2025
NARRATIVE
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Based on the review of R1's physician report dated on 2/6/2024, R1 has inappropriate behavior, aggressive behavior, and wandering behavior. Based on the review of R1's Individual Service Plan dated 6/8/2024, R1 has behavior of aggression, agitation and pacing. R1's Individual Service Plan specifies R1 constantly wanders in the hallway of memory care unit. R1 had incidents on 6/4/2024 and 6/8/2025 with the same resident. Both incidents included R1 pulling and pushing the resident and the other resident responded back by pushing R1 away, and caused R1 to have head injuries. R1's Individual Service Plan specifies redirect other residents from R1 if R1 becomes agitated and stay out of R1s' personal space when R1 gets agitated.

After the previous incidents between R1 and R2 , the facility suggested families of R1 and R2 to hire private companion. Both R1 and R2 have private companions but start 8:00AM. This incident occurred around 7:30AM, at that time there were no private caregivers and there was no staff provide supervision to R1 and R2. This is the third incident with the same residents R1 and R2, and with the similar scenario. This incident caused R1 to sustain head injuries and was sent to hospital. Facility staff neglected and lack of supervision resulted in resident R sustained head injuries..

The Department has investigated the above allegation. Based on documents reviewed, and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED.



Citations noted today. Please see LIC9099-D. Exit interview was conducted with ED. A copy of the report was provide to ED.

Page 4 of 4.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5