577005341-1-10-2024-21-AS-VBEI-CZD2KS-20240110162825

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 577005341
Report Date: 01/09/2024
Date Signed: 01/10/2024 08:52:33 AM

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
07/24/2023 and conducted by Evaluator Jill Nakagawa

COMPLAINT CONTROL NUMBER: 21-AS-20230724142905

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: 140	DATE:	01/09/2024
		UNANNOUNCED	TIME BEGAN:	11:40 AM
MET WITH:	Miriam Faris, Administrator		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Neglect/Lack of Care and Supervision resulting in severe injury
Facility in disrepair

INVESTIGATION FINDINGS:

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Licensing Program Analyst Nakagawa arrived unannounced to deliver findings of an investigation regarding the allegations that the facility’s neglect resulted in resident’s injury and that the facility is in disrepair.

The Department conducted an investigation which revealed that Staff (S1) reported that on 2/17/2023, at approximately 1800 hours, surveillance video recordings showed Resident (R1) exit through the facility's patio door leading outside unsupervised. At the same time, Staff (S2) was observed on camera in the living room area close to the patio door but did not respond to the patio door alarm. (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: 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.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 21-AS-20230724142905

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: 01/09/2024

NARRATIVE

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(Continued from 9099)

There is no indication the door chime was not working. Multiple staff stated the patio door alarm was operational and loud on the day of the incident. At approximately 1900 hours R1’s fall pad alarm went off and an alert was immediately sent to the cell phones for employees working that shift: S2, Staff (S3), Staff (S4), Staff (S5) and Staff (S6). S1 stated S3 was responsible for monitoring the living room area and responding to R1’s fall pad alarm. S1 stated video recordings showed S3 standing inside the living room and failed to respond to the alarm notification. S3 remained in the same position until S3 heard R1 banging on the door at approximately 1932 hours. R1 was left outside unsupervised for approximately one and a half hours. S6 stated R1 was cold to the touch indicating R1 had been outside for an extended period of time. R1 was a known fall risk and required additional supervision. R1 was not permitted to be in the patio area alone due to being a fall risk. R1 was transported to the hospital by ambulance and diagnosed with a hip fracture requiring surgery and hospitalization. Based on the Department’s observations, interviews conducted and records reviewed the preponderance of evidence standard has been met, therefore the allegation that neglect by the facility resulted in resident’s injury is substantiated. California Code of Regulations, Health and Safety Code (1569.269 (a) (6), are being cited on the attached LIC 9099D.

(Continued on 9099-C)

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill Nakagawa	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 21-AS-20230724142905

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: 01/09/2024

NARRATIVE

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(Continued from 9099-C)

An immediate civil penalty is being assessed today in the amount of $500 for a violation that resulted in the sickness or injury of a resident in care. The licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f).

Additionally, it is alleged that the facility’s lighting in the patio area where R1 fell was not working properly. Facility records indicate that staff were aware of the lighting not being fully functional as maintenance requests were made for repairs on “End of Shift Reports” dated 9/13/2022, 1/30/2023 and 2/19/2023. Based on the Department’s observations, interviews conducted, and records reviewed found the facility’s poor lighting in the patio area contributed to R1’s fall and injury and therefore the allegation that the facility was in disrepair is substantiated. California Code of Regulations, (Title 22, Division 6, Chapter 8, Article 5 Physical Environments and Accommodations).

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: 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

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 21-AS-20230724142905

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: 01/09/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/09/2024 Section Cited HSC 1569.269(a)(6)	1 2 3 4 5 6 7	(a) Residents…shall have…the following rights: (6) To care, supervision, and services that meet their individual needs and are delivered by staff…sufficient in number…	1 2 3 4 5 6 7	Licensee to submit a statement of understanding & submit a written plan of how they will ensure clients individual needs are met.
	8 9 10 11 12 13 14	Based on records reviewed & interviews facility didn't comply w/reg above when R1 accessed patio unsupervised, fell, and sustained injury which posed an immediate risk to the health and safety of residents in care. Immediate civil penalty of $500.00 was issued today for serious bodily injury.	8 9 10 11 12 13 14	Statement and detailed plan to be submitted to CCL by POC due date 01/10/2024.
Type A 01/09/2024 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation:(a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors…	1 2 3 4 5 6 7	Licensee to submit proof of repair to CCL by 1/10/2024, and submit plan of how repairs will be taken care of in a timely manner by 1/10/24.
	8 9 10 11 12 13 14	This requirement has not been met as evidenced by: Based on repair records lighting in patio area of Memory Care went unrepaired and contributed to the fall and injury of R1. This posed an immediate risk to the health and safety of the resident.	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: 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

LIC9099 (FAS) - (06/04)

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