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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600341
Report Date: 11/14/2024
Date Signed: 11/18/2024 08:20:44 AM

Document Has Been Signed on 11/18/2024 08:20 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 LEANDROFACILITY NUMBER:
015600341
ADMINISTRATOR/
DIRECTOR:		EVELYN JENSENFACILITY TYPE:
740
ADDRESS:1000 EAST 14TH ST.TELEPHONE:
(510) 636-0660
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY: 199CENSUS: 149DATE:
11/14/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
05:00 PM
MET WITH:Executive Director, Evelyn JensenTIME VISIT/
INSPECTION COMPLETED:
07:30 PM
NARRATIVE
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On 11/14/2024 at 5:00 PM, Licensing Program Analyst (LPA) A. Gomez conducted a Health & Safety inspection as a result of a priority 1 complaint. LPA met with Executive Director, Evelyn Jensen and explained the purpose of the visit.

LPA toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, and outdoor area. Hot water temperature was measured at 107.8 and 107.6 degrees F in random bathrooms. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Refrigerator temperature was observed at 39 degrees F. Resident's medications were kept locked in the med room. Smoke detectors are interconnected with the sprinkler system. Carbon monoxide detector observed. First-aid kit was complete. Fire extinguisher was observed to be full and last serviced on 11/3/2024. There are no accessible bodies of water observed. Indoor and outdoor passageways are free of obstruction.

LPA cited for the following:
  • LPA observed small black flying bugs in kitchen area/ food area
  • LPA observed Kitchen floors dirty and sticky.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
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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Document Has Been Signed on 11/18/2024 08:20 AM - It Cannot Be Edited


Created By: Alona Gomez On 11/14/2024 at 06:23 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 11/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/11/2024
Section Cited
CCR
87555(b)(27)

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(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of ... insects.
This requirement is not met as evidenced by:
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By POC date Facility agrees to develop and implement a plan to get rid of bugs and notify CCLD.
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Based on observation of the kitchen the Facility did not comply with the section above by the kitchen having small flying insects which poses a potential health and personal rights risk to residents in care.
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Type B
12/11/2024
Section Cited
CCR87303(a)(1)

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(a) The facility shall be clean, ... for...residents, employees and visitors.(1)Floor surfaces in ...kitchen areas shall be... clean....
This requirement is not met as evidenced by:
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By POC date Facility agrees to sanitize and clean kitchen and notify CCLD.
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Based on observation of the kitchen the Facility did not comply with the section above by the kitchen having a dirty/sticky floor which poses a potential health and personal rights risk to residents 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.
SUPERVISOR'S NAME:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Alona Gomez
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


LIC809 (FAS) - (06/04)
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