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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 577005341
Report Date: 01/09/2024
Date Signed: 01/09/2024 02:04:12 PM


Document Has Been Signed on 01/09/2024 02:04 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:CARLTON PLAZA OF DAVISFACILITY NUMBER:
577005341
ADMINISTRATOR:MIRIAM FARISFACILITY TYPE:
740
ADDRESS:2726 5TH STREETTELEPHONE:
(530) 564-7002
CITY:DAVISSTATE: CAZIP CODE:
95618
CAPACITY:150CENSUS: 140DATE:
01/09/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:57 PM
MET WITH:Miriam Faris, AdministratorTIME COMPLETED:
02:03 PM
NARRATIVE
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Licensing Program Analyst (LPA) Nakagawa arrived unannounced to conduct an inspection and deliver findings. During the course of the investigation the Department learned that the facility had failed to report the incident. Staff attempted to send the information to Community Care Licensing Regional Office, however it was not received. Staff received a "failed to send" notification and did not resend, leading the incident to go unreported as required per regulation.


Deficiency cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 8. Failure to correct the cited deficiency on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Appeal rights given.


SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2024
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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Document Has Been Signed on 01/09/2024 02:04 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 01/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/09/2024
Section Cited
CCR
87211

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87211 Reporting Requirements:(a)Each licensee shall furnish to the licensing agency such reports as the Department may require...:(1)A written report shall be submitted to the licensing agency... within seven days of the occurrence of any of the events specified... This report shall include the resident's name, age, sex and date of admission; date d disposition of the case.
(B)Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision.
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Administrator to submit the protocols staff will use to asssure that faxes and emails are sent correctly and in timely manner.
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This requirement is not met as evidenced by: **Based on records reviewed which indicate that Incident Report was not sent in timely manner which poses a possible threat to the health and safety of residents in care.
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POC due by 1/10/2024 to CCL.

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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 MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2024
LIC809 (FAS) - (06/04)
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