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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 577005341
Report Date: 04/21/2026
Date Signed: 04/21/2026 01:01:49 PM

Document Has Been Signed on 04/21/2026 01:01 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:CARLTON PLAZA OF DAVISFACILITY NUMBER:
577005341
ADMINISTRATOR/
DIRECTOR:		BLAINE LYONSFACILITY TYPE:
740
ADDRESS:2726 5TH STREETTELEPHONE:
(530) 564-7002
CITY:DAVISSTATE: CAZIP CODE:
95618
CAPACITY: 150; 150CENSUS: 144DATE:
04/21/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Blaine Lyons, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
01:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct a case management visit and gather information/records regarding incidents on 4/19/2026 self reported by the facility on 4/20/2026 that involved staff S1, S2, S3 and residents R1 and R2. LPA met with Executive Director Blaine Lyons, took statement and requested records for Community Care Licensing to review incident.

LPA reviewed video surveillance footage of the common area in the Memory Care Unit from 04/19/2026 and observed staff S1, S2 and S3 caring for residents including R1 and R2. The video shows that during the shift S1 employed the use of a bench to prevent R1 from moving off of couch and S2 and S3 moving R2 to a wheelchair and using a seatbelt to secure R2 to chair. While these restraints were used residents were continually being cared for and supervised by staff. It was observed that the restraints were removed at the arrival of the AM shift by staff S4.

LPA inspected the Memory Care Unit of the facility and found it to be clean and a comfortable temperature, with protocols in place for safe Dementia Care, including no access to hazardous materials, toxins or sharps and no use of unauthorized restraints.

LPA and Executive Director discussed ongoing training with staff.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with licensee and a copy of this report was given.
NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Jill Nakagawa
LICENSING PROGRAM ANALYST 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.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 04/21/2026 01:01 PM - It Cannot Be Edited


Created By: Jill Nakagawa On 04/21/2026 at 12:24 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
, 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: 04/21/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/21/2026
Section Cited
CCR
87608(a)(4)

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87608 Postural Supports (a)...Postural supports may be used under the following conditions. (1) ....used to achieve proper body position and balance, to improve a resident's mobility and independent functioning, or to position rather than restrict movement including, but not limited to, preventing a resident from falling out of bed, a chair, etc.

This requirement not met by licensee as evidenced by:
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Admin to submit self-certifying all facility staff will immediately cease using postural supports as a restraint by plan of correction due date of 4/22/2026.
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LPA observation of bench and postural support used as a restraint, which poses a potential health, safety or 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.
Kimberley Mota
NAME OF LICENSING PROGRAM MANAGER:
Jill Nakagawa
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST 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


LIC809 (FAS) - (06/04)
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