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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 577005341
Report Date: 03/10/2023
Date Signed: 03/10/2023 03:14:29 PM


Document Has Been Signed on 03/10/2023 03:14 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:
03/10/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Miriam Faris, AdministratorTIME COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced at Carlton Plaza of Davis to conduct a Case Management - Inspection. The purpose of this case management visit was to follow up on self reported incident report hat was submitted to Community Care Licensing (CCL) regarding resident R1 and staff S1.

During visit LPA went over incident details, gathered records, took statements from Administrator. Facility has been in contact with Police, CCL and Ombudsmans' Office. LPA will review information and will follow up with facility, once additional information is gathered and reviewed.

LPA found the facility operating with Covid-19 protocols in place: all visitors were screened, temperatures taken and masks required to be worn for entry. All staff were observed to be wearing masks and Covid-19 signage was throughout the building, reminding staff, residents and visitors to wear masks and cover coughs.

No deficiencies were found at the time of visit. No citations issued.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2023
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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