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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 577005341
Report Date: 01/09/2024
Date Signed: 01/09/2024 05:06:57 PM


Document Has Been Signed on 01/09/2024 05:06 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: 140DATE:
01/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:06 PM
MET WITH:Miriam Faris, AdministratorTIME COMPLETED:
05:10 PM
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Licensing Program Analyst (LPA) Jill Nakagawa conducted an unannounced Annual Required – 1 yr. at Carlton Plaza of Davis on 01/09/24 at approximately 02:05 PM and met with Administrator Miriam Faris. There were 140 residents present. 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 activity in Memory Care with a large group of participants. 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 11/27/23. All fire extinguishers in the facility were charged and tested on 11/27/23. 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 is also a chemical room off of the kitchen with a supply of cleaners, hygiene products and paper products available for clients which is locked and inaccessible to residents. Facility has an Infection Control Plan. All bathrooms were provided with hand soap and paper towels. Water temperature in bathrooms inspected measured 117 - 117.4 F.

There were no deficiencies or citations issued during this inspection.

Exit interview conducted with Administrator, Miriam Faris.

SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2024
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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