577005341-10-19-2024-21-AS-KMOA-DACSA8-20241024134151

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 577005341
Report Date: 10/19/2024
Date Signed: 10/19/2024 02:03:59 PM

Unsubstantiated

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
07/22/2024 and conducted by Evaluator Jill Nakagawa

COMPLAINT CONTROL NUMBER: 21-AS-20240722163924

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:	10/19/2024
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Genai Bradshaw, Memory Care Activities Director (Acting Facilities Manager)		TIME COMPLETED:	02:05 PM

ALLEGATION(S):

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Staff do not ensure residents toileting needs are met in a timely manner
Staff are not providing residents with adequate food service
Staff do not keep the facility free from odor
Staff did not address changes to resident's physical, medical, mental, and social condition

INVESTIGATION FINDINGS:

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On 10/19/2024 LPA Nakagawa arrived unannounced to conclude an investigation and deliver findings regarding the above allegations. LPA met with the acting facilities director of the day, Genai Bradshaw, Memory Care Activities Director.

The complaint alleges that staff are not providing residents with adequate food service. LPA conducted facility visits on 07/24/2024 and 10/19/2024. LPA observed breakfast and lunch service in the memory care (MC) and assisted living units (AL). LPA observed an ample supply of food, which appeared to be varied and of high quality, meeting the nutritional standards as required per Title 22. LPA observed staff assisting residents who required help with feeding; staff prompted or assisted residents as needed. In addition to 3 meals a day, there are also snacks and hydration breaks available throughout the day.

Continued on 9099-C

Unsubstantiated

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: 10/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20240722163924

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: 10/19/2024

NARRATIVE

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Continued from 9099....

Based on LPA’s observations, interviews, and records reviewed, there is no evidence to support the allegation that staff are not providing residents with adequate food service. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Staff did not address changes to resident's physical, medical, mental, and social condition. LPA made observations, conducted interviews, and reviewed records and found that staff monitor all residents for changes in condition. LPA reviewed physician reports and care plans. The care team is aware of residents’ needs and continuously monitor for changes in condition and did not find any evidence of changes not being addressed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur therefore the allegation that staff did not address changes to resident’s physical, medical, mental, and social condition is unsubstantiated.

Staff do not keep the facility free from odor: LPA conducted facility visits on 7/24/2024 and 10/19/2024 and found resident rooms in memory care to be clean and odor-free. LPA inspected rooms in the Assisted Living section on the same dates and found no concerns for cleanliness or observed any odors. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation that Staff do not keep the facility free from odor is unsubstantiated.

Staff do not ensure residents toileting needs are met in a timely manner: LPA made observations and reviewed records. LPA conducted facility visits on 07/24/2024 and 10/19/2024 and found that residents appeared clean and dressed appropriately. A review of records found that hygiene and toileting needs are logged regularly by staff which show that toileting is conducted approximately every two hours. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation that Staff do not ensure residents toileting needs are met in a timely manner is unsubstantiated.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill Nakagawa	TELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2024

LIC9099 (FAS) - (06/04)

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