577005341-1-17-2023-21-AS-JNAA-CN6RFZ-20230117115957

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 577005341
Report Date: 01/17/2023
Date Signed: 01/17/2023 12:00:05 PM

Document Has Been Signed on 01/17/2023 12:00 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 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: 139	DATE:	01/17/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	MIriam Faris, Administrator		TIME COMPLETED:	12:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Jill Nakagawa conducted an unannounced Annual Required – 1 yr. Infection Control inspection at Carlton Plaza of Davis on 01/17/23 at approximately 09:30 AM and met with Administrator Miriam Faris. There were 139 residents present. LPA arrived at the facility and had temperature checked, screening questions asked and information then logged. During facility tour with Administrator, facility was found to be clean and at a comfortable temperature of 74 F with all exits free from obstruction. At the time of inspection there was an entertainer in Memory Care and free Covid testing was being provided. Several residents' apartments, common areas, kitchen & food storage areas, Memory Care Unit, and outside sitting areas were inspected. Fire Extinguishers and Fire Protection System were inspected by Cosco Fire Protection on 11/23/22. All fire extinguishers in the facility were charged and tested on 11/28/22. Inspection of the kitchen showed there was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator and freezer were properly stored as per regulations on this day at the time of the visit. Toxins and dangerous items are stored in laundry room behind locked doors; providing inaccessibility to residents. There was a supply of cleaners, hygiene products and paper products available for clients (locked in storage cabinet).

Facility has submitted a mitigation program plan that was approved on 02/09/21, as well as an Infection Control Plan. There are postings throughout the facility, including common area bathrooms, illustrating proper hand washing procedures, along with hand soap and paper towels. The facility provides constant communication with staff, family, the State, and Yolo County regarding testing and positive cases. All staff were observed to be wearing masks.

There were no deficiencies or citations issued during this inspection.

Exit interview conducted with Administrator, Miriam Faris.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill Nakagawa	TELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023

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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