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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600341
Report Date: 12/18/2024
Date Signed: 12/18/2024 03:09:43 PM

Document Has Been Signed on 12/18/2024 03:09 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
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: 151DATE:
12/18/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Executive Director, Evelyn JensenTIME VISIT/
INSPECTION COMPLETED:
03:20 PM
NARRATIVE
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On 12/18/2024 at 2:00PM Licensing Program Analysts (LPAs) A Gomez J Clancy-Czuleger arrived unannounced to conduct a POC visit in relation to the deficiencies issued on 11/14/2024. LPAs met with Executive Director, Evelyn Jensen and explained the purpose of the visit. The facility is licensed for 199 residents of which 115 may be non-ambulatory.

On 11/14/2024 LPA A Gomez conducted a case management visit and cited for the following:

87555(b)(27): On 11/14/2024 LPA observed insects in the kitchen. POC is now clear.

87303(a)(1): On 11/14/2024 LPA observed dirty floors and surfaces in the kitchen. POC is now clear.

On 12/18/2024 LPAs observed the following Deficiency:


  • Food is not being properly stored in the kitchen. LPAs observed open raw chicken, uncovered peaches, and other improperly stored foods in the refrigerators.


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: 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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/18/2024 03:09 PM - It Cannot Be Edited


Created By: Alona Gomez On 12/18/2024 at 02:49 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: 12/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/30/2024
Section Cited
CCR
87555(b)(9)

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(b)The following...shall apply: (9) Procedures which protect the safety, ...of food shall be observed in food storage, preparation and service.
This requirement was not met as evidence by
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By POC Facility agrees t oreview the food storage and properly store all improperly stored food in the kitchen and notify CCLD.
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Based on observation the Licensee did not comply with the section cited above with having improperly stored food in the kitchen refridgerators which poses a potential health and safety 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: 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


LIC809 (FAS) - (06/04)
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