577005341-2-4-2025-21-AS-JNAA-DDKVEU-20250204152255

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 577005341
Report Date: 02/04/2025
Date Signed: 02/04/2025 03:23:01 PM

Document Has Been Signed on 02/04/2025 03:23 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 DAVIS		FACILITY NUMBER:	577005341
ADMINISTRATOR/ DIRECTOR:	MIRIAM FARIS		FACILITY TYPE:	740
ADDRESS:	2726 5TH STREET		TELEPHONE:	(530) 564-7002
CITY:	DAVIS	STATE: CA	ZIP CODE:	95618
CAPACITY: 150	TOTAL ENROLLED CHILDREN: 0	CENSUS: 137	DATE:	02/04/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:26 AM
MET WITH:	Mina Kutulas, Director of Resident Services		TIME VISIT/ INSPECTION COMPLETED:	03:22 PM

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On 02/04/2025, Licensing Program Analyst (LPA) Jill Nakagawa, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Resident Care Director Mina Kutulas and explained the purpose of the visit.

LPA Nakagawa and Mina Kutulas toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms of Memory Care unit, common restrooms, kitchen, dining room, actvities rooms and several resident apartments. LPA observed the facility to be clean, in good repair and odor-free. Each bathroom to have the necessary grab bars, non-skid flooring or shower chair, paper towels, trash can with lids. LPA observed each bedroom to have the necessary furnishings with working lights and windows with screens. LPA received multiple compliments from AL residents regarding care and food.

Facility has a 2-day perishable and a 7-day non-perishable amount of food and sharps to be locked. LPA observed several fire extinguishers, fire/smoke detectors. LPA observed the first aid kit to be complete and ready for use.

In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA reviewed a total of five (5) residents' files and five (5) staff files which contained all the required documentation. Resident files were on-line but are accessible by staff at any time. LPA was able to find all required documentation.

Several topics were discussed.

No deficiencies are being cited as a result of today’s inspection.

Exit interview conducted and copy of report left at the facility.

Kimberley Mota	TELEPHONE: (707) 588-5051
Jill Nakagawa	TELEPHONE: 707-588-5063
	DATE: 02/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025

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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