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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 577005341
Report Date: 05/30/2024
Date Signed: 05/30/2024 02:04:25 PM


Document Has Been Signed on 05/30/2024 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: 142DATE:
05/30/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Miriam Faris, AdministratorTIME COMPLETED:
02:05 PM
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An informal meeting was conducted today in the Santa Rosa Regional Office. Present in the meeting were Licensing Program Manager, Kimberley Mota, Licensing Program Analyst, Jill Nakagawa, Administrator, Miriam Faris, Vice President of Corporate Development, Lindsay Flores and, VP Clinical Operations, Marco Santos.

The purpose of the informal meeting was to discuss an incident that occurred at the facility on February 17, 2023 that resulted in a complaint investigation with substantiated findings. In addition, the following areas of concern were discussed:

*Adequate staffing in the memory care unit: training of staff to include understanding the importance of staggered breaks. In addition, Administrator to monitor the care needs of residents and proper staffing levels to meet these needs.

*Administrator's Duties: Administrator to ensure adherence to reporting requirements, ensuring safety of buildings and grounds.

Administrator has implemented: Evening supervisor (2:30 PM to 10:45 PM) whose primary duty is not to provide care giving (although they are trained if needed), but to oversee evening operations. In addition Administrator states that facility has implemented a "hero position" which is an additional staff member where needed.

Continued on LIC809-C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2024
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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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
VISIT DATE: 05/30/2024
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Documents requested during informal meeting to be submitted to CCL by May 31,2024.:

· Licensee will submit an updated LIC500 indicating staff coverage in all areas of the facility..

No deficiencies cited during today’s informal conference office visit.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024
LIC809 (FAS) - (06/04)
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