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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015600341
Report Date: 12/04/2025
Date Signed: 12/04/2025 03:26:57 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
08/27/2025 and conducted by Evaluator Tonica Syess-Gibson
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250827161242
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: 149DATE:
12/04/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH: Angela Turin,Executive DirectorTIME COMPLETED:
03:40 PM
ALLEGATION(S):
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The facility broiler is in disrepair, leaving the building without hot water
Staff do not ensure resident needs are met
INVESTIGATION FINDINGS:
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On 12/04/2025 at 10:00AM, Licensing Program Analysts (LPAs) T. Syess-Gibson and Yasamine Brown arrived unannounced to deliver complaint findings for the allegations above. LPAs met with Executive Director, Angela Turin and explained the purpose of the visit.

Allegation: The facility broiler is in disrepair, leaving the building without hot water

Interviews with staff and residents revealed that the facility’s boiler malfunctioned and burst, leaving the facility without hot water for two (2) days. During this time, residents were unable to take hot showers or baths.
Continue on LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2025
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-20250827161242
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: 12/04/2025
NARRATIVE
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Continued from LIC9099


Allegation: Staff do not ensure resident needs are met

Interviews with residents revealed that staff were not making rounds every two (2) hours. Residents also stated during interview, staff only check on them when the call button is pressed or when Alexa is used to contact the front desk for assistance.

Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D.


Exit interview conducted with Evelyn Jenson. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20250827161242
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: 12/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/11/2025
Section Cited
CCR
87303(a)
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(a) The facility shall be clean, safe, sanitary and in good repair at all times....

This requirement was not met as evidence by:
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By POC date, facility agrees to read regulation 87303 and send a self certifying email to CCLD.
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Based on interviews and record review the licensee did not comply with the section cited above in having a malfunctioning broiler which posed a personal rights and potential health and safety risk to persons in care.
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Type B
12/11/2025
Section Cited
CCR
87468.2(a)(4)
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(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities,...:(4) To care, supervision, and services...This requirement was not met as evidence by:

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By POC date, the facility agrees to implement a plan to ensure staff is sufficient in numbers to meet the needs of residents care.
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Based on observation the Licensee did not comply with the section cited above in not having sufficient in numbers to meet the needs of residents care. which poses a personal rights and potential health and safety 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: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2025
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
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
08/27/2025 and conducted by Evaluator Tonica Syess-Gibson
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250827161242

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: 149DATE:
12/04/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Angela Turin,Executive DirectorTIME COMPLETED:
03:40 PM
ALLEGATION(S):
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9
Staff do not ensure that all residents are provided a means to call for assistance
INVESTIGATION FINDINGS:
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On 12/04/2025 at 10:00AM, Licensing Program Analysts (LPAs) T. Syess-Gibson and Yasamine Brown arrived unannounced to deliver complaint findings for the allegations above. LPAs met with Executive Director, Angela Turin and explained the purpose of the visit.

Allegation: Staff do not ensure that all residents are provided a means to call for assistance

Interview with ED revealed, all residents are given call buttons on lanyards upon admission and pull cords are installed in residents’ rooms. Interviews with residents revealed facility did provide call buttons and they are functioning.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4