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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200727
Report Date: 11/06/2023
Date Signed: 11/07/2023 09:18:33 AM


Document Has Been Signed on 11/07/2023 09:18 AM - 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: 138DATE:
11/06/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Shantela YadaoTIME COMPLETED:
03:25 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced Case Management - Incident visit and met with Administrator (ADM) Shantela Yadao.

On 11/06/2023, LPA Chang interviewed staff S1- who stated that Resident (R1) was found on the floor of R1's bedroom on 11/3/2023 at 7:00AM in Assisted Living found by staff (S2).

911 was called immediately, around 7:15AM on 11/3/2023. R1 was assessed by paramedics, R1 was pronounced dead at 7:25AM.

LPA interviewed 4 Staff (S1 - S4) and Administrator (ADM). LPA interviewed two Family members (FM1, FM2) of resident (R1).

LPA obtained R1's Physician Report, Medication list and Care Plan and notes.

4 Out of 4 staff stated that R1 was weak due to cancer and was on oxygen 24 hours due to short of breath.

ADM stated that R1 was seen on 11/3/02023 at 4:50AM by a NOC shift staff (S5) in his/her bedroom and was fine. On 11/3/2023, at 7:00AM, R1 was found on the floor unresponsive of his/her bedroom.


Continue on LIC809-C. Page 1 of 2.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 11/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


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: 11/06/2023
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Both Family members of R1 stated R1 was getting weaker, and his/her medical/health condition was declining. Both stated they don't have any complaint against the facility; they were supposed to have a meeting with the facility and hospice care agency today, 11/6/23.

This case needs further investigation. ADM will update CCL office when R1's death certificate is available.

Exit interview was conducted with ADM. The report was provided to ADM for signature. A copy the report was provided to ADM.


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

DATE: 11/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2