Carlton Plaza Of Davis

On July 1, 2025, Program Analyst (LPA) Nakagawa arrived unannounced to continue a complaint investigation and deliver findings on the above allegations. LPA spoke with Administrator Blaine Lyons. The complaint alleges that Staff do not respond to residents’ call lights for assistance in a timely manner. LPA requested call light records for 1/20/25 through 2/19/2025. There were 310 calls in Memory Care for that time frame. LPA looked at a sample of the records for 1/20/25 through 1/23/25 and found 59 calls; with 53 of those calls being answered within 1-4 minutes. There were 4 calls that took between 13-38 minutes and 2 calls that took between 1 hour and 11 minutes and 1 hour and 15 minutes. Although most of the response times were well within best practices, the two calls that took over an hour demonstrate that Staff do not respond to residents’ calls for assistance in a timely manner; other days examined within the time frame of 1/20/25 to 2/19/25 had similar findings: 2/13/25 throughRead the full finding— CDSS inspection report, July 1, 2025 · control 21-AS-20250219114000

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) SubstantiatedRead the full finding— CDSS inspection report, May 6, 2025 · control 21-AS-20250131155017

On 10/19/2024 LPA Nakagawa arrived unannounced to conclude an investigation and deliver findings regarding the above allegations. LPA met with the acting facilities director of the day, Genai Bradshaw, Memory Care Activities Director. The complaint alleges that staff are not providing residents with adequate food service. LPA conducted facility visits on 07/24/2024 and 10/19/2024. LPA observed breakfast and lunch service in the memory care (MC) and assisted living units (AL). LPA observed an ample supply of food, which appeared to be varied and of high quality, meeting the nutritional standards as required per Title 22. LPA observed staff assisting residents who required help with feeding; staff prompted or assisted residents as needed. In addition to 3 meals a day, there are also snacks and hydration breaks available throughout the day. Continued on 9099-C UnsubstantiatedRead the full finding— CDSS inspection report, October 19, 2024 · control 21-AS-20240722163924

Licensing Program Analyst Nakagawa arrived unannounced to deliver findings of an investigation regarding the allegations that the facility’s neglect resulted in resident’s injury and that the facility is in disrepair. The Department conducted an investigation which revealed that Staff (S1) reported that on 2/17/2023, at approximately 1800 hours, surveillance video recordings showed Resident (R1) exit through the facility's patio door leading outside unsupervised. At the same time, Staff (S2) was observed on camera in the living room area close to the patio door but did not respond to the patio door alarm. (Continued on 9099-C) SubstantiatedRead the full finding— CDSS inspection report, January 9, 2024 · control 21-AS-20230724142905

On 9/29/2022 Licensing Program Analyst (LPA) Nakagawa arrived at Carlton Plaza unannounced to deliver findings to the facility regarding the above allegation and was greeted by Administrator, Miriam Faris. During the investigation, the Department toured the facility, reviewed records, and conducted interviews with staff, clients and outside parties. The complaint alleges that the facility did not notice a change in condition of resident (R1). Based on the LPA’s interviews with staff, residents, outside parties and a review of care notes, the 602, pre-assessment, medical records, and resident documents (Care Tracker) which show dates and times of resident (R1) being fed, toileted, receiving grooming assistance and attempts at medication administration; whether completed or refused. Records also indicate multiple calls to PCP, family, and EMS. Based on this information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged viRead the full finding— CDSS inspection report, September 29, 2022 · control 21-AS-20220902085213

Licensing Program Analysts (LPAs) Jill Nakagawa and Chris Arnhold arrived unannounced and met with Miriam Faris, Administrator to continue this complaint investigation and deliver findings. During the course of this investigation, the facility was toured, records were reviewed, and interviews conducted. The above allegation alleges that a resident had a fall resulting in injury then passed away. LPA reviewed resident records and found that, although resident did suffer two falls over the course of 5 days, EMS and Hospice agencies were contacted at the time and assessed the resident. The evaluation resulted in resident not being transported to the hospital for care or treatment. Review of the Death Certificate show the cause of death was not related or a result of the fall. This agency has investigated the complaint alleging Questionable Death. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable baRead the full finding— CDSS inspection report, April 28, 2022 · control 21-AS-20220127102600

Licensing Program Analyst (LPA) Jill Nakagawa and Chris Arnhold arrived unannounced and met with Miriam Faris, Administrator to continue this complaint investigation and deliver findings. During the course of this investigation, the facility was toured, records were reviewed, and interviews conducted. Residents not being provided services – this complaint alleges that the residents are not being provided showers, being fed, nor being provided bathroom services. LPA reviewed resident documents which show dates and times of residents being fed, toileted, and receiving grooming assistance. These reports demonstrate that the residents are indeed being fed regularly, bathroom services are being provided and showering assistance is provided. Report showed the date and time of a shower, whether it was completed or refused, and how much time was spent with the resident. LPA reviewed 6 months’ worth of staffing records for the facility and found facility had staff to meet the needs of the residRead the full finding— CDSS inspection report, April 28, 2022 · control 21-AS-20220228111741

Licensing Program Analyst (LPA) Nakagawa arrived unannounced and met with LIndsey Feifert, Director of Resident Services, to continue this complaint investigation and deliver findings. During the course of this investigation the facility was toured, records and photos were reviewed and interviews conducted. It is alleged that Resident not provided bed linens. Photographs and observation revealed that the bed of R1 was not made correctly. Per regulation the licensee shall provide clean linens, which include a top sheet, bottom sheet, pillow cases, mattress pads, blankets and bedspread. The proper bottom bed sheet was lacking on more than one occasion, therefore this allegation is substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Continued on 9099-C SubstantiatedRead the full finding— CDSS inspection report, March 23, 2022 · control 21-AS-20220124085943