435200727-1-9-2026-26-AS-RMAO-DR3387-20260206170104

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435200727
Report Date: 01/09/2026
Date Signed: 01/09/2026 10:30:41 AM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/26/2025 and conducted by Evaluator Simranjit Rai

COMPLAINT CONTROL NUMBER: 26-AS-20250626171730

FACILITY NAME:	CARLTON PLAZA OF SAN JOSE		FACILITY NUMBER:	435200727
ADMINISTRATOR:	SHANTELA YADAO		FACILITY TYPE:	740
ADDRESS:	380 BRANHAM LANE		TELEPHONE:	(408) 972-1400
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95136
CAPACITY:	183	CENSUS: 94	DATE:	01/09/2026
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Administrator, Shantela Yadao		TIME COMPLETED:	10:45 AM

ALLEGATION(S):

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Facility staff are not properly addressing resident’s behaviors.
Facility did not ensure the resident received an updated medical assessment after a change of condition.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with the Administrator, Shantela Yadao and stated the purpose of today’s visit.

On 6/26/2025, the Department received a complaint with the above allegations. On 7/2/2025, the Department conducted an initial investigation at the facility. On 8/25/2025, the Department conducted an additional investigation at the facility.

Continuation on LIC 9099-C, Page 1 of 3.

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2026

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 3

Control Number 26-AS-20250626171730

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: CARLTON PLAZA OF SAN JOSE	FACILITY NUMBER: 435200727
	VISIT DATE: 01/09/2026

NARRATIVE

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Page 2 of 3.

On 6/19/2025, the resident (R1) had an unwitnessed fall at the facility and facility staff called 911 and R1 was transported to the hospital for medical assessment. On 6/20/2025, the resident returned back to the facility with new medication orders. On 6/21/2025, the facility staff noticed a change of condition where R1 had behaviors wherein R1 was confused and was verbally aggressive towards facility staff and family members. The facility staff called 911 and law enforcement arrived and assessed the resident, and they did not deem the resident required Emergency Medical Transportation (EMT).

Facility staff are not properly addressing residents’ behaviors.
It was alleged the resident’s behavior expressed on 6/21/2025 was not being addressed by the facility staff.

On 7/2/2025, LPA Rai interviewed 3 staff who are aware of the incident of 6/21/2025. Three out of three staff stated resident started having behaviors after R1’s hospitalization on 6/20/2025. Three out of three staff stated there was a change of condition on 6/20/2025 as R1 was hospitalized and medications were changed. Three out of three staff stated this was R1's initial behavioral expression on 6/21/2025 and they are working with R1’s family and R1’s physician to ensure R1 is being provided with the appropriate care. S1 stated R1’s physician was contacted regarding the incident on R1 and did not provide any new orders for facility staff to follow.

Based on review R1’s progress notes, there were no documented notes of R1’s behavior prior to 6/20/2025. LPA Rai reviewed change of medication order during hospital discharge on 6/20/2025, R1’s physician discontinued 2 medications on R1’s medication list.
Based on review of R1's Individual Service Plan from 6/29/2023 – 6/23/2025, the facility staff did not mention R1 having any behaviors prior to 6/23/2025. LPA Rai reviewed R1’s Individual Service Plan for 6/23/2025, wherein R1’s Agitation behavior and action plan for staff providing R1’s care needs, which includes for staff to call 911 when agitation becomes a safety concern. LPA Rai reviewed the communication note faxed to R1’s physician on 6/21/2025 and noted R1’s physician did not provide new orders.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20250626171730

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: CARLTON PLAZA OF SAN JOSE	FACILITY NUMBER: 435200727
	VISIT DATE: 01/09/2026

NARRATIVE

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Page 3 of 3.

Facility did not ensure the resident received an updated medical assessment after a change of condition.

On 7/2/2025, LPA Rai interviewed 3 staff (S1-S3) who are aware of the incident of 6/21/2025. Three out of three staff stated R1 had an initial behavioral expression on 6/21/2025 and they are working with R1’s family and R1’s physician to ensure R1 is being provided with the appropriate care. S1 stated R1’s physician was contacted regarding the incident on R1 and did not provide facility staff with new orders or appointments for R1. S2 and S3 stated the facility staff called 911 on the day of 6/21/2025 and the law enforcement arrived and assessed the resident, and they did not deem the resident required Emergency Medical Transportation (EMT). S1 stated they reached out to R1's physician to update about R1's change of condition so R1's physician can determine if R1 required a medical assessment after the incident on 6/21/2025. S1 stated R1's physician responded to the update with no new orders or appointments for R1, so the facility staff continued to monitor R1 for any additional behavioral expressions or changes of condition.

On 8/25/2025, LPA Rai interviewed 2 staff (S4-S5). S5 was not aware if R1 received an updated medication assessment after the incident on 6/21/2025. S4 stated he/she noticed a change in R1, but R1 was not assessed by physician after the incident on 6/21/2025.

LPA Rai reviewed the communication note faxed to R1’s physician on 6/21/2025 and noted R1’s physician signed the document to acknowledge receiving the note and did not provide new orders or appointments for R1 to follow up from the incident on 6/21/2025.

The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Administrator, Shantela Yadao and a copy of the report was provided.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2026

LIC9099 (FAS) - (06/04)

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