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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 577005341
Report Date: 04/28/2022
Date Signed: 04/28/2022 03:08:15 PM

Unfounded


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
01/27/2022 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20220127102600
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: 137DATE:
04/28/2022
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Miriam Faris, AdministratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Questionable Death
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analysts (LPAs) Jill Nakagawa and Chris Arnhold arrived unannounced and met with Miriam Faris, Administrator to continue this complaint investigation and deliver findings. During the course of this investigation, the facility was toured, records were reviewed, and interviews conducted.
The above allegation alleges that a resident had a fall resulting in injury then passed away. LPA reviewed resident records and found that, although resident did suffer two falls over the course of 5 days, EMS and Hospice agencies were contacted at the time and assessed the resident. The evaluation resulted in resident not being transported to the hospital for care or treatment. Review of the Death Certificate show the cause of death was not related or a result of the fall.

This agency has investigated the complaint alleging Questionable Death. We have found that the complaint
was unfounded, meaning that the allegation was false, could not have happened
and/or is without a reasonable basis.
No citations issued.

Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
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 2
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
01/27/2022 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20220127102600

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: 137DATE:
04/28/2022
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Miriam Faris, AdministratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Neglect/Lack of supervision resulted in resident sustaining pressure injuries while in care.
Staff are not meeting resident's hygiene needs.
Staff did not provide food service to residents.
Neglect/Lack of Supervision resulted resident falls with injury(ies).
Staff did not ensure resident received timely medical attention.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analysts (LPAs) Jill Nakagawa and Chris Arnhold arrived unannounced and met with Miriam Faris, Administrator to continue this complaint investigation and deliver findings. During the course of this investigation, the facility was toured, records were reviewed, and interviews conducted.
Based on records reviewed and interviews conducted, there is no specific information given regarding which residents may have pressure injuries or where they are located. LPA interviewed staff and it was explained that residents are inspected for any skin issues during baths and changes and any concerns would be brought to the attention of one of the Community Nurses. Staff not meeting resident's hygiene needs was investigated and review of resident care records indicate that continence and hygiene were taken care of by the facility as required and documented in the Care Record. Care plans and interviews with staff show that residents were bathed and changed as needed. LPA reviewed menus from June 2021 through January 2022 that showed food served met regulation. LPA reviewed resident records, Incident Reports, and Hospice documentation which showed that when a fall occurred or a change in condition is observed, EMS or medical professionals were contacted to conduct an assessment. Facility updated resident service plan as needed. Facility notified resident physician, hospice, and family or responsible person as required per regulation. Based on this information, 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 is unsubstantiated. No citations issued
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 2