577005341-9-29-2022-21-AS-KMOA-CK6SHY-20221013135418

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 577005341
Report Date: 09/29/2022
Date Signed: 09/29/2022 10:03:50 AM

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
09/02/2022 and conducted by Evaluator Jill Nakagawa

COMPLAINT CONTROL NUMBER: 21-AS-20220902085213

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: 135	DATE:	09/29/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Miriam FAris		TIME COMPLETED:	10:15 AM

ALLEGATION(S):

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9

Facility did not notice change of resident condition.

INVESTIGATION FINDINGS:

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On 9/29/2022 Licensing Program Analyst (LPA) Nakagawa arrived at Carlton Plaza unannounced to deliver findings to the facility regarding the above allegation and was greeted by Administrator, Miriam Faris. During the investigation, the Department toured the facility, reviewed records, and conducted interviews with staff, clients and outside parties.
The complaint alleges that the facility did not notice a change in condition of resident (R1). Based on the LPA’s interviews with staff, residents, outside parties and a review of care notes, the 602, pre-assessment, medical records, and resident documents (Care Tracker) which show dates and times of resident (R1) being fed, toileted, receiving grooming assistance and attempts at medication administration; whether completed or refused. Records also indicate multiple calls to PCP, family, and EMS.
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 deficiencies cited at today’s inspection. No citations issued.
Exit interview conducted.

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: 09/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022

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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