577005341-3-23-2022-21-AS-KMOA-CEZMWY-20220602095907

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 577005341
Report Date: 03/23/2022
Date Signed: 03/23/2022 02:54:57 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/24/2022 and conducted by Evaluator Jill Nakagawa

COMPLAINT CONTROL NUMBER: 21-AS-20220124085943

FACILITY NAME:	CARLTON PLAZA OF DAVIS		FACILITY NUMBER:	577005341
ADMINISTRATOR:	MIRIAM FARIS		FACILITY TYPE:	740
ADDRESS:	2726 5TH STREET		TELEPHONE:	(530) 564-7002
CITY:	DAVIS	STATE: CA	ZIP CODE:	95618
CAPACITY:	150	CENSUS: 135	DATE:	03/23/2022
		UNANNOUNCED	TIME BEGAN:	01:19 PM
MET WITH:	Lindsey Feifert, Director of Resident Services		TIME COMPLETED:	02:55 PM

ALLEGATION(S):

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Resident not provided bed linens
Facility is not following proper protocol for COVID-19

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Nakagawa arrived unannounced and met with LIndsey Feifert, Director of Resident Services, to continue this complaint investigation and deliver findings. During the course of this investigation the facility was toured, records and photos were reviewed and interviews conducted.

It is alleged that Resident not provided bed linens. Photographs and observation revealed that the bed of R1 was not made correctly. Per regulation the licensee shall provide clean linens, which include a top sheet, bottom sheet, pillow cases, mattress pads, blankets and bedspread. The proper bottom bed sheet was lacking on more than one occasion, therefore this allegation is substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Continued on 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill Nakagawa	TELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022

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 3

Control Number 21-AS-20220124085943

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: CARLTON PLAZA OF DAVIS	FACILITY NUMBER: 577005341
	VISIT DATE: 03/23/2022

NARRATIVE

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Continued from 9099

It is alleged that Facility is not following proper protocol for COVID-19. During the course of the investigation, photographs and interviews were conducted showing that used PPE was not properly doffed by staff; nor was it properly discarded, stored or removed during an active case of Covid-19, therefore this allegation is substantiated.

A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiencies and/or repeat deficiencies within a 12 month period may result in civil penalties. Appeal rights given.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill Nakagawa	TELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 21-AS-20220124085943

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: CARLTON PLAZA OF DAVIS	FACILITY NUMBER: 577005341
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/23/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/23/2022 Section Cited CCR 87470(b)(2)(B)	1 2 3 4 5 6 7	87470 Infection Control Requirements (b) (2)All staff...providing direct care to resident who has a communicable disease shall wear appropriate... PPE ...(B)PPE shall be...discarded in the nearest... receptacle with... immediately upon completing a task. This requirement has not been met as evidence by:	1 2 3 4 5 6 7	Licensee to submit proof of training of staff on proper PPE donning, doffing and proper disposal following mitigation plan submitted to CCL on 01/20/2021. Proof submitted to LPA during visit 03/23/22.
	8 9 10 11 12 13 14	Based on photos, observation, interviews and record review Licensee did not follow mandated guidance of mitigation plan and failed to discard PPE in a tightly-lidded container as required which poses a potential health, safety, and personal rights risk to clients in care.	8 9 10 11 12 13 14
Type B 03/23/2022 Section Cited CCR 87307(a)(3)(C)	1 2 3 4 5 6 7	87307 Personal Accommodations and Services (a)(3)(a)...Living accommodations..The following provisions shall apply:(3) Equipment... personal care and maintenance...each resident...provide the following.. (C)Clean linen, including... bottom bed sheets,...The linen shall be in good repair.	1 2 3 4 5 6 7	LIcensee to submit proof of supply of the proper bed linens required and photos documenting that beds are made correctly with the required bed linens submitted to CCL by 03/23/22. Proof submitted to LPA during visit on 03/23/22.
	8 9 10 11 12 13 14	This requirement has not been met as evidence by: Based on photos, observation, Licensee failed to provide the resident required bottom bed sheet in 2 out of 2 days which poses a potential health, safety, and personal rights risk to clients in care.	8 9 10 11 12 13 14

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: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill Nakagawa	TELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022

LIC9099 (FAS) - (06/04)

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