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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 577005341
Report Date: 02/04/2025
Date Signed: 02/04/2025 03:50:20 PM

Document Has Been Signed on 02/04/2025 03:50 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/
DIRECTOR:		MIRIAM FARISFACILITY TYPE:
740
ADDRESS:2726 5TH STREETTELEPHONE:
(530) 564-7002
CITY:DAVISSTATE: CAZIP CODE:
95618
CAPACITY: 150CENSUS: 137DATE:
02/04/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:47 PM
MET WITH:Miriam Faris, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived on February 4, 2025 for an unannounced Case Management visit to follow up on substantiated complaint allegations: complaint number 21-AS-20230724142905. LPA met with Miriam Faris, Administrator and explained the purpose of the visit.

On January 9, 2024, the Department concluded an investigation which alleged that Neglect/Lack of Care and Supervision resulting in severe injury and Facility in disrepair.

The allegations were substantiated, and the licensee was cited for violating Health and Safety Code (H&S) §1569.269(a)(6) Enumerated rights; and California Code of Regulations (CCR) Title 22 §87303(a) Maintenance and Operation.



At the time of the complaint visit on January 9, 2024, an immediate civil penalty for Health and Safety Code §1569.269(a)(b) of $500 was issued. The licensee was informed that an additional civil penalty was being determined and might be assessed based on Health and Safety Code §1569.49.

The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code §15610.67 defines serious bodily injury as "an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by the facilities lack of supervision on February 17, 2023, when a resident (R1) who was identified as a fall risk and required additional supervision, was able to exit the patio door, go outside unsupervised and fall.

Continued on 809-C

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: 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)
Page: 1 of 2
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: 02/04/2025
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Continued from 809....

Staff (S1) last observed R1 at approximately 1800 hours sitting in a wheelchair near the patio door. Staff (S2) reported that on February 17, 2023, at approximately 1800 hours, surveillance video showed R1 exit the patio door and go outside unsupervised. Staff (S3), who was covering for S4 who was on break, was observed on camera in the living room area close to the patio door and did not turn around or respond to the patio door alarms. While outside unattended on the unlit patio for approximately one and a half hours, R1 fell and sustained a fractured hip resulting in hospitalization and surgery.

Today February 4, 2025, the Department is issuing a civil penalty per Health and Safety Code §1569.49 for a violation that the Department constitutes as serious bodily injury resulting in the hospitalization of a resident, in the amount of $10,000. However, since an immediate civil penalty of $500 was previously issued on January 9, 2024, the amount of the civil penalty issued today will be $9,500.

Exit interview conducted. A copy of the report has been issued. Appeal rights provided. Facility representative and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

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
LIC809 (FAS) - (06/04)
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