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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200727
Report Date: 08/11/2022
Date Signed: 08/11/2022 02:46:53 PM


Document Has Been Signed on 08/11/2022 02:46 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
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: 89DATE:
08/11/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Shantela Yadao, ED TIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced Case Management visit today, and met with Executive Director (ED) Shantela Yadao.

LPA interviewed ED regarding the incident. An updated incident report, resident physician report, Appraisal Needs and Service Plan, and the facility staff training document were obtained.

ED stated the facility will provide more training to staff.

The Department need further investigation for this incident.

There is no citation for today's investigation.

Exit interview was provided to ED. This report was provided to ED for signature. A copy of this report was provided to ED.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2022
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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