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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200727
Report Date: 12/08/2020
Date Signed: 12/08/2020 04:38:20 PM

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:JENNELL REVERAFACILITY TYPE:
740
ADDRESS:380 BRANHAM LANETELEPHONE:
(408) 972-1400
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY:183CENSUS: 130DATE:
12/08/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jennell ReveraTIME COMPLETED:
11:50 AM
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At 11:00AM Licensing Program Analysts (LPAs) Steve Chang, Gladys Kuizon, and Program Clinical Consultant Elenteny Barbara conducted a tele visit with PCC via zoom platform. Due to COVID-19 preventive measures, facility visits have been suspended. LPAs met with Executive Director (ED) Jennell Revera. The facility currently has 19 residents in Memory Care Unit and 111 residents in Assisted Living Unit. ED stated the facility provides meal room service for the residents in Assisted Living Unit due to COVID-19.

During today's inspection, facility was virtually toured thoroughly. The facility has the COVID related posters, hand sanitizer, thermometer, and visitor sign in log at the main entrance. The COVID-19 related posters displayed at the common area, hallway, activity room, dinning room, and restroom. Paper towel, liquid soap, hand sanitizer were observed in the kitchen and restrooms. Some of the trash cans were observed without lids. ED stated the facility already ordered trash cans with lids to replace trash cans without lids. The restrooms in resident rooms have the COVID related signs, paper towel, liquid soap, and hand sanitizer. Beds in the share resident rooms were observed 6 feet apart. The tables and chairs in the Memory Care Unit dining room were observed less than 6 feet apart. During the inspection, the residents of the Memory Care Unit were using the lunch. The residents in memory care dining room were observed less than 6 feet apart. The residents isolation room has sign posted and door is closed.

The following recommendations were given today, ED stated the facility will followed the recommendations.

Please see Continuation 809-C
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2020
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: 12/08/2020
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1. All the trash bins must have lids.
2. Ensure dining room seating in Memory Care is configured at least 6 feet of social distance between residents.

No deficiencies cited during today's Tele Visit. A copy of this report is emailed to the facility for signature.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2020
LIC809 (FAS) - (06/04)
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