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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200727
Report Date: 09/15/2021
Date Signed: 09/16/2021 08:56:27 AM

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: 85DATE:
09/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:59 AM
MET WITH:SHANTELA YADAO, EDTIME COMPLETED:
01:59 PM
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At 11:59AM, Licensing Program Analyst (LPA) Steve Chang arrived at the facility. Upon arrival, the front desk staff conducted an infection control/prevention screening, and body temperature check, then logged LPA in visitor logs.

LPA met with Executive Director (ED) Shantela Yadao. LPA addressed the purpose of today's visit to ED.

LPA toured the facility inside out with ED. LPA inspected the dinning room and activity rooms of Assisted Living Unit. LPA inspected the resident apartment rooms of Assisted Living Unit. LPA inspected the staff offices, LPA inspected the dinning room and resident apartment rooms in Memory Care Unit. The public restrooms. Salon room, mailbox room, kitchen, and laundry room were inspected. The backyard of Assisted Living Unit and backyard of Memory Care Unit were inspected.

ED stated all the residents are fully vaccinated. ED stated around 85% staff are fully vaccinated. LPA observed the facility conducted the COVID test for the unvaccinated staff in the facility.

LPA observed the exits and elevators have the hand sanitizers. LPA observed not all the trash cans in the public area and in the public restrooms had covers. ED stated the facility will change the trash cans to be trash cans with covers.

LPA observed the beds in the shared rooms have 6 feet apart. LPA observed all the staff wore the masks.

Continuation see LIC809-C
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021
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: 09/15/2021
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5717LPA discussed and reviewed LIC808 with ED. ED stated the facility will follow COVID protocol.

No citation was issued for today's inspection. An exit interview was conducted with ED. This report was provided to ED to review and to sign. A copy of this report was emailed to ED.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021
LIC809 (FAS) - (06/04)
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