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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 577005341
Report Date: 05/06/2025
Date Signed: 05/06/2025 03:23:03 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/31/2025 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20250131155017
FACILITY NAME:CARLTON PLAZA OF DAVISFACILITY NUMBER:
577005341
ADMINISTRATOR:MIRIAM FARISFACILITY TYPE:
740
ADDRESS:2726 5TH STREETTELEPHONE:
(530) 564-7002
CITY:DAVISSTATE: CAZIP CODE:
95618
CAPACITY:150CENSUS: 139DATE:
05/06/2025
UNANNOUNCEDTIME BEGAN:
12:52 PM
MET WITH:Miriam Faris, AdministratorTIME COMPLETED:
03:25 PM
ALLEGATION(S):
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Staff are not taking precautions to mitigate the spread of illness in the facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) opened an investigation regarding the above allegation and found the following through the conducting of interviews and reviewing documents.
The Administrator stated that the facility’s Infection Control Plan abides by the strictest protocols in place when giving care to residents. On 12/30/2024 the Administrator was aware of resident (R1) experiencing vomiting, and diagnosed with pneumonia. This was reported to CCL on 1/08/2025. There were no other cases reported to CCL until 1/31/2025. Administrator informed CCL by email that there were several residents with GI issues. Residents were notified by written notice posted at their doors of the increase in cases, courtesy room service was extended to all residents; dining room remained open.
(Continued on 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025
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 3
Control Number 21-AS-20250131155017
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: CARLTON PLAZA OF DAVIS
FACILITY NUMBER: 577005341
VISIT DATE: 05/06/2025
NARRATIVE
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(Continued from 9099...)

According to Administrator, Yolo County Dept. of Public Health (CDPH) was also contacted on 1/31/2025 and a line list of cases submitted to CDPH on 2/1/2025 and CCL on 2/3/2025. According to the line list there were four cases of vomiting and/or diarrhea which had been reported to Administrator on 01/28/2025. CCL and CDPH guidelines require notification within 24 hours when there is an outbreak (3 or more cases). The allegation that Staff are not taking precautions to mitigate the spread of illness in the facility is substantiated. Based on review of records the preponderance of evidence standard has been met: Administrator did not notify the Department in the required timeframe therefore the above allegation is found to be SUBSTANTIATED. (Deficiency cited)

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and Health and Safety Code (cited on 9099-D). Appeal rights given to the former Licensee. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20250131155017
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: CARLTON PLAZA OF DAVIS
FACILITY NUMBER: 577005341
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
05/06/2025
Section Cited
CCR
87211(a)(2)
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87211 (a)A written report shall be submitted to the licensing agency...within seven days of the occurrence of.. (2)Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate.
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Administrator discussed plan for training with LPA on 5/6/2025. Administrator to conduct in-service training with all care staff and management team on the proper reporting requirements as outlined in CCR 87211.
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This requirement was not met as evidenced by: Based on reporting records Licensee did not report outbreak within the required 24 hours.

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Administrator will submit a signed training log with names of attendees, date, time, location and subject of the training, and who conducted the training to CCL by POC due date 05/12/25.
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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: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025
LIC9099 (FAS) - (06/04)
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