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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015600341
Report Date: 04/21/2026
Date Signed: 04/21/2026 01:25:40 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
11/13/2024 and conducted by Evaluator Alona Gomez
COMPLAINT CONTROL NUMBER: 15-AS-20241113154936
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: 136DATE:
04/21/2026
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Angie Turin, Executive DirectorTIME COMPLETED:
01:40 PM
ALLEGATION(S):
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9
Staff physically abused resident resulting in bruises.
Staff financially abused resident.
Resident's rooms are malodorous.
Staff do not ensure food is properly disposed.
INVESTIGATION FINDINGS:
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On 4/21/2026 at 10:00 AM, Licensing Program Analysts (LPAs) A. Gomez and Y. Brown arrived unannounced to deliver findings for the above allegations. LPA met with Executive Director, Angie Turin and explained the purpose of the visit.

During course of the investigation, the Department conducted interviews with facility staff, witnesses and complainant. Documents including but not limited to: Residents Admission agreements, physician’s reports, care plans, medication logs, incident reports, photos of residents, discharge notes, and R1’s Death Certificate were reviewed and or obtained.

Report continues on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2026
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 7
Control Number 15-AS-20241113154936
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: 04/21/2026
NARRATIVE
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Pg 2

On the allegation of staff physically abused resident resulting in bruises LPA’s conducted interviews with residents, staff, witnesses, and obtained photos. On 3/21/2025 LPA’s interviewed R2 Who stated that sometimes when staff bathe them, they are too rough. LPA‘s interviewed W6 who states that they noticed bruising on R2 when they came to visit them. W6 states that when they asked R2 what happened they stated that W3 had left the bruises because they were being too rough while bathing them. W6 states that they were informed the bruises were a result of W3 grabbing R2 too tightly. W6 states that a police report was not made because W3 had already been fired. LPA‘s obtained photographs that showed R2 had sustained bruising on both forearms. LPAs observed that the bruising is consistent with being grabbed, therefore, the allegation of staff physically abused resident resulting in bruises is substantiated.

On the allegation of staff financially abused resident the department conducted interviews, obtained documentation, and conducted a financial audit. During the investigation LPA’s interviewed R4 who stated that in late 2024 they were being financially abused. LPA’s interviewed S2 through S12. S1, S2, S11, and W1 stated that they had all heard of a resident having been financially abused by the previous Resident Liaison (W2) however they were not sure if it was true. LPA interviewed the previous executive director who stated that they had reported possible financial abuse to the San Leandro police department, but nothing further came of the investigation. LPA‘s requested potential documentation of financial abuse on 3/21/2025 . Previous Executive Director stated that they did not have record of any proof of financial abuse. On 6/12/2025 LPA’s return to the facility and again requested documentation of financial abuse and the executive Director was able to produce a document stating the name of employee of former resident liaison (W2) on an official bank document for R4. LPA’s then requested a financial audit of R4’s bank accounts on 8/06/2025. The financial audit revealed that W2 had been getting direct transfers from R4’s bank account to their personal account. Therefore, the allegation of staff financially abused resident is substantiated.

Report Continues on LIC9099-C

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 15-AS-20241113154936
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: 04/21/2026
NARRATIVE
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Pg 3
On the allegation residents rooms are malodorous LPA’s toured the facility on 3/21/2025. While touring the facility on 3/21/2025, LPA’s observed on the second floor a strong smell of human urine. LPA’s briefly spoke to a staff member passing by name unknown, who stated that urine is a common odor in that part of the facility. LPA’s were able to locate the odor in R17’s room. LPA observed that R17 utilizes a catheter and that urine was spilling onto the floor. LPA’s interviewed R17 who states that staff do not come to assist in cleaning the urine and that they are charged extra if they need their floors cleaned. During the course of the investigation LPAs also conducted interviews with S1 and S6. S1 states that staff should be cleaning the floors and also S1 stated that rooms are cleaned on an annual schedule however if a resident has an accident on the floor that they need to come down to the front desk to ask for their room to be cleaned. S6 states that they have noticed lingering urine odors before. Therefore, the allegation of resident's rooms are Malodorous is substantiated


On the allegation, staff did not ensure food is properly disposed LPA’s toured the facility and made observations. On 8/21/2025 LPA’s observed in R4’s room food with mold and expired in their refrigerator. The food observed was covered in saran wrap, and in dishes provided during tray service. At the time of the Observation, LPA’s observed R4 was bed bound and on full care. LPA‘s interview S1 who stated that R4 was currently receiving tray service and incontinence care. LPAs found through interviews that staff are expected to deliver the trays and then return a few hours later to retrieve the dishes and trays after meal times. LPAs also interviewed S2 and S10 who stated that they have noticed staff not removing trays as required and food leftovers not being disposed of properly. Therefore, the allegation of staff did not ensure food is properly disposed is substantiated.

Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

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: 04/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 15-AS-20241113154936
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: 04/21/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/05/2026
Section Cited
CCR
87468.2(a)(8)
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(a)In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (8)To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse.

This requirement was not met as evidence by:
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By POC date, the facility agrees to conduct 2 hours of training on personal rights and Reporting Requirements with an approved CCLD vendor and send proof of training to CCLD.
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Based on interviews and record review, the licensee did not comply with the section cited above in R4 being financially abused by previous staff member (W2) which posed an immediate personal rights risk to persons in care.
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Type A
05/05/2026
Section Cited
CCR
87413(a)(2)
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(a)In each facility:(2)Care and supervision of residents shall be provided without physical or verbal abuse, exploitation or prejudice.


This requirement was not met as evidence by:
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By POC date, the facility agrees to review personal rights and provide in-service to all staff on proper bathing procedures and provide the training materials to CCLD.
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Based on interviews and photos, the licensee did not comply with the section cited above in R2 sustaining bruises on both arms while being showered by W3 which posed an immediate 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: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 15-AS-20241113154936
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: 04/21/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/05/2026
Section Cited
CCR
87625(b)(3)
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(b)In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3)Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.

This requirement was not met as evidence by:
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By POC date, the facility agrees to develop a semi-annual carpet cleaning schedule and provide the rooms and dates that are being cleaned.
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Based on interviews and observations made by LPAs, the licensee did not comply with the section cited above in R17s room smelling of urine which posed a potential personal rights risk to persons in care.
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The facility also agrees to create a plan for the residents known to have incontinence care and provide the time and dates and send these plans to CCLD.
Type B
05/05/2026
Section Cited
CCR
87303(f)
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(f)All waste shall be located, stored, and disposed of in a manner that will not transmit communicable diseases or odors, pose a risk to health and safety, or provide a breeding place or food source for insects or rodents.

This requirement was not met as evidence by:
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By POC, the facility agrees to check all of the residents rooms and develop a daily check sheet for staff to ensure that all rooms are free of trays and discarded food by the end of the night midnight and send the sheet to CCLD.
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Based on observations made by LPAs, the licensee did not comply with the section cited above in R4s room having moldy and expired foods while R4 was on full care and bed bound which posed a potential 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: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 7
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
11/13/2024 and conducted by Evaluator Alona Gomez
COMPLAINT CONTROL NUMBER: 15-AS-20241113154936

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: 136DATE:
04/21/2026
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Angie Turin, Executive Director TIME COMPLETED:
01:40 PM
ALLEGATION(S):
1
2
3
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9
Questionable death.
Staff do not ensure resident's showering needs are being met.
INVESTIGATION FINDINGS:
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On 4/21/2026 at 10:00 AM, Licensing Program Analysts (LPAs) A. Gomez and Y Brown arrived unannounced to deliver findings for the above allegation. LPA met with Executive Director, Angie Turin and explained the purpose of the visit.

During course of the investigation, the Department conducted interviews with facility staff, witnesses and complainant. Documents including but not limited to: Residents Admission agreements, physician’s reports, care plans, medication logs, incident reports, photos of residents, discharge notes, and R1’s Death Certificate

Report continues 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 15-AS-20241113154936
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: 04/21/2026
NARRATIVE
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On the allegation of “Questionable Death” the Department obtained copies of the death report for R1. After a review it was found that R1 passed away from ventricular arrhythmia and coronary artery disease. LPA’s also reviewed R1’s medical records and physicians reports and observed that R1 had related pre-existing conditions. Therefore the allegation of Questionable Death is unsubstantiated

On the allegation of “Staff do not ensure residents showering needs are being met” LPAs interviewed R2, R3, R4, R7, and R8 . R2 and R7 both stated that their showering needs are being met. LPAs also reviewed shower logs and care plans. LPAs observed that showers are being provided and care plans are being followed in regards to showering needs therefore the allegation Staff do not ensure resident's showering needs are being met is unsubstantiated

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.



Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2026
LIC9099 (FAS) - (06/04)
Page: 7 of 7