577005341-4-28-2022-21-AS-KMOA-CF9NWM-20220610104944

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 577005341
Report Date: 04/28/2022
Date Signed: 04/28/2022 03:09:56 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
02/28/2022 and conducted by Evaluator Jill Nakagawa

COMPLAINT CONTROL NUMBER: 21-AS-20220228111741

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: 137	DATE:	04/28/2022
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	MIriam Faris, Administrator		TIME COMPLETED:	03:25 PM

ALLEGATION(S):

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Residents are not being provided services.
Facility is not staffed adequately.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) 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.
Residents not being provided services – this complaint alleges that the residents are not being provided showers, being fed, nor being provided bathroom services. LPA reviewed resident documents which show dates and times of residents being fed, toileted, and receiving grooming assistance. These reports demonstrate that the residents are indeed being fed regularly, bathroom services are being provided and showering assistance is provided. Report showed the date and time of a shower, whether it was completed or refused, and how much time was spent with the resident.
LPA reviewed 6 months’ worth of staffing records for the facility and found facility had staff to meet the needs of the residents.
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 Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill Nakagawa	TELEPHONE: 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)

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