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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015600341
Report Date: 05/23/2024
Date Signed: 05/23/2024 04:30:23 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/22/2024 and conducted by Evaluator James Sampair
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240522100917
FACILITY NAME:CARLTON PLAZA OF SAN LEANDROFACILITY NUMBER:
015600341
ADMINISTRATOR:EVELYN JENSENFACILITY TYPE:
740
ADDRESS:1000 EAST 14TH ST.TELEPHONE:
(510) 636-0660
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY:199CENSUS: 150DATE:
05/23/2024
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Executive Director Evelyn JensenTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Third floor of the facility has too many non-ambulatory residents.
INVESTIGATION FINDINGS:
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On 5/23/2024 at 11:45 AM, Licensing Program Analysts (LPAs) J. Sampair and A. Gharachorloo arrived unannounced to investigate the allegation above. The LPAs informed Executive Director Evelyn Jensen of the reason for the visit.

The complaint alleges that on the 3rd floor of the facility there are too many nonambulatory residents.
Based on a review of facility records, the fire clearance is for 6 nonambulatory residents for the third floor, but 19 are currently living on the third floor, which is 13 more than allowed.

Continues on LIC9099 . . .
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024
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 3
Control Number 15-AS-20240522100917
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CARLTON PLAZA OF SAN LEANDRO
FACILITY NUMBER: 015600341
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/30/2024
Section Cited
CCR
87202(a)(1)
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87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by … fire protection services … Prior to accepting or retaining any of the following types of persons, … licensee shall … obtain an appropriate fire clearance …. (1) Nonambulatory persons.

This requirement is not met as evidenced by:
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On or before the due date, licensee shall submit application to CCLD for an increase of nonambulatory residents to at least accommodate the current number of residents for the 3rd floor of the facility including a sketch of the facility.
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Based on review of facility records, there are 19 nonambulatory residents living on the 3rd floor, but the facility is licensed for a capacity of only 6 nonambulatory residents for the 3rd floor, which poses a potential health, safety, or personal rights risk to persons in care.
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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: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20240522100917
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: CARLTON PLAZA OF SAN LEANDRO
FACILITY NUMBER: 015600341
VISIT DATE: 05/23/2024
NARRATIVE
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.... Continued from LIC9099

The complaint is substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies are cited per Title 22 California Code of Regulations as listed on the LIC 9099-D.

Additionally, due to the severity of the deficiency, a $500.00 immediate civil penalty is assessed today.

Exit interview conducted with Executive Director and a copy of this report was provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3