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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015600341
Report Date: 12/18/2024
Date Signed: 12/18/2024 03:01:24 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
05/01/2024 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20240501124551
FACILITY NAME:CARLTON PLAZA OF SAN LEANDROFACILITY NUMBER:
015600341
ADMINISTRATOR:NANCY RANDHAWAFACILITY TYPE:
740
ADDRESS:1000 EAST 14TH ST.TELEPHONE:
(510) 636-0660
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY:199CENSUS: DATE:
12/18/2024
UNANNOUNCEDTIME BEGAN:
01:59 PM
MET WITH:Evelyn Jensen, Executive DirectorTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff did not seek timely medical attention for a resident
INVESTIGATION FINDINGS:
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On December, 18, 2024 at 2:00 pm Licensing Program Analyst (LPA) J. Clancy-Czuleger and A. Gomez arrived unannounced to deliver findings on the above allegation. LPA met with Facility Supervisor Evelyn Jensen and explained the purpose of the visit.

The Department’s investigation included but was not limited to interviews with current staff, witnesses, residents, and the collection and review of records from the hospital and facility.

The facility's incident report indicated Resident (R1) was given the wrong medications at 0845 hours on February 8, 2024, yet the facility called Kaiser’s advice line at 0947 hours. A review of the Kaiser Permanente medical records showed that Falck ambulance was told R1 was given the wrong medications at 1000 hours, and she was not transported to the Emergency Department (ED) until 1057 hours. Staff (S1) interviewed said R1 was given the wrong medications between 0830-0900 hours.

Continued on 9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2024
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 4
Control Number 15-AS-20240501124551
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: CARLTON PLAZA OF SAN LEANDRO
FACILITY NUMBER: 015600341
VISIT DATE: 12/18/2024
NARRATIVE
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...Continued from 9099

Once S1 realized his error, he reported to front desk after 3-5 minutes. The Licensed Vocational Nurse (S3) responded to monitor R1. Although other measures were attempted to raise R1’s blood pressure, S3 knew it would not drastically help. Further, S3 said she knew R1’s blood pressure would significantly drop and R1’s condition would decline. However, the advice from another nurse (S4) was for S3 to continue monitoring R1 and to call an ambulance only when R1 began showing signs of decline.

The preponderance of evidence standard has been met; therefore, the above allegation(s) were found to be substantiated.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties.
Exit interview conducted. Appeal Rights and a copy of this report provided via email.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 15-AS-20240501124551
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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: 12/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/30/2024
Section Cited
CCR
87466
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The licensee shall ensure that residents are regularly observed for changes...that appropriate assistance is provided when such observation reveals unmet needs…..
This requirement is not met as evidenced by…
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By POC date, Administrator states that:
1. Record of the in-service training that was held on emergency calls for residents for staff, and any updated training
2. Administrator will read the regulation and submit self-certification stating understanding
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Based on records review and interview, the licensee did not comply with the section cited above by not calling medical attention for the resident until an hour after the error had occurred and did not call for transported until two hours after the error had occurred which posed an health and safety risk to the resident.
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Proof of correction will be sent to CCLD by POC date
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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: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
05/01/2024 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20240501124551

FACILITY NAME:CARLTON PLAZA OF SAN LEANDROFACILITY NUMBER:
015600341
ADMINISTRATOR:NANCY RANDHAWAFACILITY TYPE:
740
ADDRESS:1000 EAST 14TH ST.TELEPHONE:
(510) 636-0660
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY:199CENSUS: DATE:
12/18/2024
UNANNOUNCEDTIME BEGAN:
01:59 PM
MET WITH:Evelyn Jensen, Executive DirectorTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff neglect resulted in a resident's death
INVESTIGATION FINDINGS:
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On December, 18, 2024 at 2:00 pm Licensing Program Analyst (LPA) J. Clancy-Czuleger and A. Gomez arrived unannounced to deliver findings on the above allegation. LPA met with Facility Supervisor Evelyn Jensen and explained the purpose of the visit.

The Department reviewed records and conducted interviews. Based on R1's medical records and R1’s death certificate showed R1 had fallen off of her hospital bed on 2/13/2024, had surgery, and died on 3/2/2024 from complications of blunt hip trauma.

We have found that the above allegation was Unfounded, meaning that the allegation was false, could not have happened and/or is without reasonable basis. Therefore, this allegation is unfounded.
Exit Interview conducted and a copy of this report provided.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4