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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 577005341
Report Date: 07/01/2025
Date Signed: 07/01/2025 04:49:38 PM

Substantiated


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
02/19/2025 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20250219114000
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: 136DATE:
07/01/2025
UNANNOUNCEDTIME BEGAN:
03:04 PM
MET WITH:Blaine Lyons, AdministratorTIME COMPLETED:
04:50 PM
ALLEGATION(S):
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Staff do not respond to residents' call for assistance in a timely manner
Staff do not follow residents' care plan

INVESTIGATION FINDINGS:
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On July 1, 2025, Program Analyst (LPA) Nakagawa arrived unannounced to continue a complaint investigation and deliver findings on the above allegations. LPA spoke with Administrator Blaine Lyons.

The complaint alleges that Staff do not respond to residents’ call lights for assistance in a timely manner. LPA requested call light records for 1/20/25 through 2/19/2025. There were 310 calls in Memory Care for that time frame. LPA looked at a sample of the records for 1/20/25 through 1/23/25 and found 59 calls; with 53 of those calls being answered within 1-4 minutes. There were 4 calls that took between 13-38 minutes and 2 calls that took between 1 hour and 11 minutes and 1 hour and 15 minutes. Although most of the response times were well within best practices, the two calls that took over an hour demonstrate that Staff do not respond to residents’ calls for assistance in a timely manner; other days examined within the time frame of 1/20/25 to 2/19/25 had similar findings: 2/13/25 through 2/18 /25 showing responses to 61 calls with 53 taking less than 10 minutes,

Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025
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 6
Control Number 21-AS-20250219114000
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/01/2025
NARRATIVE
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Continued from 9099....

6 taking 15 to 44 minutes and three calls taking from 1.56 hours to 3 + hours therefore the allegation is substantiated. (See 809D for the deficiency cited).

The complaint alleges Staff do not follow the resident’s care plan. The complainant states some residents’ care plans state they need 2-person assistance due to needing a Hoyer lift, or for incontinence care, and staff have been told to do it on their own. The complainant stated resident R2 is a fall risk, and management said they need to be watched one on one. The complainant stated that it wasn’t communicated to all staff, and R2 fell out of bed 2/13/25. LPA spoke with staff S1 who reported that R2 had enhanced care services 1:1 between 1/22/2025 until 5/13/2025, which were clearly listed in the care plan which is completed by care staff members. The care records for R2 show they had enhanced care services and were receiving additional supports including escorts to and from activities and meals, mealtime support, hourly checks. According to S1, on 2/13/2025 R2 didn't fall but slid out of bed; there were no injuries (the facility utilizes Safely You camera). LPA conducted interviews and found that 6 out of 6 staff stated the company policy for care staff who are providing care independently must ask for assistance from another staff member when providing care for a Hoyer lift or a 2-person assist. Zero of 6 staff stated that they were instructed to initiate care alone for a two person assist. However, 2 of 6 staff members interviewed stated that if they did not receive a timely response to their request for assistance the staff member would aid the resident alone, despite the company policy. Therefore, the allegation that staff do not follow the care plan is substantiated. (See 809D for the deficiency cited).

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Continued on 9099-A

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

DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
02/19/2025 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20250219114000

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: DATE:
07/01/2025
UNANNOUNCEDTIME BEGAN:
03:04 PM
MET WITH:Blaine Lyons, AdministratorTIME COMPLETED:
04:50 PM
ALLEGATION(S):
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9
Staff do not ensure that resident is repositioned
Staff do not prevent residents from engaging in inappropriate behavior

INVESTIGATION FINDINGS:
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On July 1, 2025, Program Analyst (LPA) Nakagawa arrived unannounced to continue a complaint investigation and deliver findings on the above allegations. LPA spoke with Administrator Blaine Lyons.

The complaint alleges that Staff do not ensure that resident is repositioned. LPA requested the care and hospice notes for resident (R1). Resident records from 1/20/2025 to 2/19/2025 indicate that R1 received continence care every two hours and was repositioned at that time, as ordered per care plan, as well as checks every 45 minutes. Documentation by care team indicate that care took place. RP stated on 2/17/25, they heard another caregiver say R1 had redness on their skin from not being repositioned in an unknown location on R1. Hospice made visits twice a week and made no notations of pressure injuries or redness.


Continued on 9099-Ca
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 21-AS-20250219114000
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/01/2025
NARRATIVE
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Continued from 9099-A

Medication list does show barrier cream to be applied once per day but makes no reference to any redness or other concerns. Therefore the allegation that Staff do not ensure that resident is repositioned is unsubstantiated.

The complaint alleges Staff do not prevent residents from engaging in inappropriate behavior. The reporting party stated 2 residents (R3 and R4) were found in bed together. Based on interviews LPA found that staff did not anticipate the behavior of residents R3 and R4. During a group activity staff noticed R3 and R4 missing from an activity and when they went to check on them R3 and R4 were found together in bed; an activity within their personal rights. There was no incident report filed citing any abuse or misconduct, and responsible parties were notified. Although it may have been unanticipated residents were exercising their personal rights - not engaging in inappropriate behavior, therefore the allegation that Staff do not prevent residents from engaging in inappropriate behavior is unsubstantiated.

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

DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
02/19/2025 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20250219114000

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: DATE:
07/01/2025
UNANNOUNCEDTIME BEGAN:
03:04 PM
MET WITH:Blaine Lyons, AdministratorTIME COMPLETED:
04:50 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not follow reporting requirements
INVESTIGATION FINDINGS:
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The complaint alleges that Staff do not follow reporting requirements. The reporting party stated that they did not believe residents’ families were notified of the incident between R3 and R4. LPA spoke with staff (S1) who stated that they had spoken with the responsible parties and provided text messages of calls made to the responsible parties therefore the allegation that Staff do not follow reporting requirements is UNFOUNDED.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 21-AS-20250219114000
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/01/2025
Section Cited
CCR
87411(a)
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87411 Personnel Requirements - General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to meet resident needs.....for the provision of adequate services. This requirement was not met as evidenced by:

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Plan of Correction shall include a plan for retraining Memory Care staff as it relates to answering call lights in a timely manner. In addition,
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Based on interviews and record review,LPA observed Call Light logs from January 20, 20253 through February 19, 2025 in which residents would push the call buttons and the response times were exceeding over 60+ minutes. This is a potential health, safety and personal rights risk to the residents in care.

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Administrator discussed with LPA a plan for going forward with re-training completed by 7/8/2025.

Type B
07/01/2025
Section Cited
HSC
1569.2(b)
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Health and Safety Code section 1569.2(b):(b) "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with taking medications, money management, or personal care.
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Plan of Correction shall include a plan for retraining Memory Care staff as it relates to 2-person assists. Administrator will submit proof of training
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This requirement was not met as evidenced by: Based on interviews, staff ignored company policy of using 2-person assist when care plan called for a 2-person assist and worked independently, not waiting for assistance.
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to LPA by 7/8/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6