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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 577005341
Report Date: 08/26/2022
Date Signed: 08/26/2022 12:51:24 PM


Document Has Been Signed on 08/26/2022 12:51 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:MIRIAM FARISFACILITY TYPE:
740
ADDRESS:2726 5TH STREETTELEPHONE:
(530) 564-7002
CITY:DAVISSTATE: CAZIP CODE:
95618
CAPACITY:150CENSUS: 132DATE:
08/26/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Miriam Faris, Administrator TIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct an unannounced inspection focusing on Covid-19 protocols. The facility had reported cases in Memory Care Unit, over the last few weeks, but there have been no new cases in the last 10 days, and residents are off quarantine and isolation.

Administrator, Miriam Faris showed LPA around the facility with particular focus on the Memory Care Unit. All residents were dressed appropriately and well-groomed. Most of the residents were enjoying lunch at the time of visit, with care staff serving and monitoring residents as they ate. The unit was clean and orderly, with all used PPE and trash disposed of properly. All staff were observed to be wearing masks and gloves. No faceshields or gowns were necessary as there are no identified active cases of Covid-19 in MC, or the rest of the facility. Weekly response testing has been taking place but due to end soon.

The rest of the facility was enjoying life as usual, with the dining room in full operation, although diners were socially distancing. Visitors are enjoying access to the facility but must wear masks and are being screened before entry. Activities, such as Bingo and Exercise are taking place each day, with social distancing being practiced.

Staff and residents were pleasant and interactive.

There were no deficiencies found at the time of inspection.
No citations issued.



SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2022
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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