Carlton Plaza of Fremont

Allegation investigated: Staff did not provide proper food service to resident in care Staff did not ensure that the facility had telephone services for residents in care Passageways accessible to residents in care is not kept free of obstructions Staff did not provide adequate care and supervision Facility elevator is in disrepair Staff provided the wrong medication to resident in care Resident was not provided with contracted facility amenities Staff left resident unattended resulting in a fall Staff did not implement proper infection control practices Staff exposed residents to a hazardous chemicals

On 05/07/2026 at 8:55 AM, Licensing Program Analyst (LPA) P. Manalo arrived unannounced to conducted more interviews and deliver the findings on the above allegations. LPA met with Executive Director, Gianni Amari, and explained the purpose of the visit. During the course of investigations, LPA interviewed ED, S1, S2, S3, S4, S5, S6, S7, S8, S9, S10, and R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, and R12. LPA also interviewed W1, W2, and W3. LPA toured the facility, collected and reviewed documents including but not limited to resident roster, email correspondence, elevator invoices, housekeeping schedules, Personnel Report (LIC500), facility incident report, service plan, facility’s medication verification/ doctor’s order, pharmacy contact information, residents' Admission Agreement, Physician Report, Resident Health Identification Information, Service Plans, Facility Incident Report notes, Email Correspondence of Maintenance Issue, Email Correspondence of Health Outbreaks, Amenities Documentation, Residents' Monthly Invoice, Continue to LIC9099-C... Unsubstantiated Continue from LIC9099... January Food Menu, and Monthly Task Log. Allegation: Staff did not provide proper food service to resident in care. It was alleged that staff did not provide proper food service to resident in care. Interview with 10 of 12 residents indicated that the food is cooked well and that they haven’t had any issues with uncooked or raw food. Interview with S2 revealed the kitchen staff will use a food thermometer to check if it’s cooked thoroughly and once the food is cooked, kitchen staff will place it in a food warmer before meal services. Based on interviews conducted, the above allegation that staff did not provide proper food service to resident in care 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 allegations are unsubstantiated. Allegation: Staff did not ensure that the facility had telephone services for residents in care. It was alleged that staff did not ensure that the facility had telephone services for residents in care. Interview with W2 indicated that someone at the front desk will usually either pick up or call back right away if W2 calls the facility. W2 indicated that they have not experienced any issues getting ahold of someone in the facility when needed. Interview with R1 stated that R1 has an Alexa and a cellphone in their room. LPA observed that R1 has two Alexa in the room. In addition, Interview with R11 revealed that R11 was provided with Alexa services and R11 can use Alexa to call staff for assistance. On 02/05/2026, LPA observed that R11 used Alexa to call staff for assistance and staff responded right away. Based on interviews and observations conducted, the above allegation that staff did not ensure that the facility had telephone services for residents in care 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 allegations are unsubstantiated. Continue to LIC9099-C... Continued from LIC9099-C... Allegations: Passageways accessible to residents in care is not kept free of obstructions. It was alleged that passageways accessible to residents in care is not kept free of obstructions. On 01/30/2026, LPA observed that there was a dumpster bin outside in the parking lot away from the passageway. On 04/28/2026, LPA P. Manalo and K. Nguyen observed multiple trash bins outside in the parking lot away from the passageway. Interview with S6 indicated that when the trash and recycle is scheduled to be picked up, the gate will be open until it’s done. S6 stated that the side gate will only be opened during the scheduled pick-up day. Interview with W2 indicated that there have been no issues with the handicapped area in the parking lot being blocked off with anything. Interview with R4 and R5 stated that they use the handicapped parking in the back parking lot frequently and never had any issues with the passageway blocked. R4 stated that there were trash bins outside in the parking lot at times, but it never blocked the passageway to enter the facility. 5 of 5 residents interviewed revealed that they never encountered any issues with passageways blocked inside and outside of the facility. Based on interviews and observations conducted, the above allegation that passageways accessible to residents in care are not kept free of obstructions 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 allegations are unsubstantiated. Allegation: Staff did not provide adequate care and supervision It was alleged that staff did not provide adequate care and supervision. Interviews with 9 of 12 all indicated that they are getting the care that they need at the facility. Interview with 2 of 12 residents indicated that they are independent and don’t require any care and supervision from the staff. Interview with W2 and W3 indicated that there are no issues with care in the facility for their residents. During interview with R1, R1 stated that R1 is comfortable and that the facility takes good care of R1. Continue to LIC9099-C... Continued from LIC9099-C... R1 also included that the staff is assisting and meeting the needs of R1. Based on interviews conducted, the above allegation that staff did not provide adequate care and supervision 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 allegations are unsubstantiated. Allegation: Facility elevator is in disrepair. It was alleged that the facility elevator is in disrepair. On 10/21/2025, LPA received an email from ED that the elevator in the back of the facility will be undergoing maintenance for approximately 6 weeks. Per email, it indicated that there will be two other elevators that residents and visitors can use in the meantime. On 01/30/2026, LPA observed that the elevator in the back was still undergoing maintenance per signage posted on the elevator. On 04/28/2026, LPA P. Manalo and K. Nguyen observed 2 of 3 elevators functioning and 1 of 3 elevators undergoing repair. Interview with ED on 04/28/2026 indicated that with the elevators constantly in repair, the facility decided to do a modernization for all 3 elevators. Interview with 5 of 5 residents indicated that all 3 elevators have not been out of service all at once and that at least one elevator is in use for the residents. Based on interviews and observations conducted, the above allegation that facility elevator is in disrepair 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 allegations are unsubstantiated. Allegation: Staff provided the wrong medication to resident in care. It was alleged that staff provided the wrong medication to residents in care. Interview with 5 of 5 residents that are receiving medication management all stated that they have received their medication on time and don’t think they’ve received the wrong medication. R1 stated that staff will hand R1 their medication and will wait until R1 has taken it. R1 also stated that they never had any issues with their medication. Continue to LIC9099-C... Continued from LIC9099-C... Based on interviews and observations conducted, the above allegation that staff provided the wrong medication to resident in care 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 allegations are unsubstantiated. Allegation: Resident was not provided with contracted facility amenities. It was alleged that the resident was not provided with contracted facility amenities. A review of R1’s admission agreement dated on 02/01/2022 revealed that the utilities provided for R1 will only include water, electricity, garbage service, heat and air conditioning. The residents will be responsible for their own installation of other services such as telephone or cable. Interview with R1 says that they have a cellphone to use if needed. Interview with 4 residents stated that there are Wi-Fi connections provided by the facility for residents to use in the common areas such as the café or the library. Based on review of documents and interview conducted, the above allegation that resident was not provided with contracted facility amenities 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 allegations are unsubstantiated. Allegation: Staff left resident unattended resulting in a fall. It was alleged that staff left residents unattended resulting in a fall. A review of the facility’s internal incident report dated 03/26/2026 indicated that R1 pressed their pendant and staff found R1 sitting on the floor beside R1’s bed. R1 was reported to have slid off the bed and felt okay. Per incident report, the facility staff notified R1’s responsible party and R1 did not sustain any injuries. Continued to LIC9099-C.... Continued from LIC9099-C... Based on review of documents conducted, the above allegation that staff left resident unattended resulting in a fall 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 allegations are unsubstantiated. Allegation: Staff did not implement proper infection control practices. It was alleged that staff did not implement proper infection control practices. A review of the facility’s incident report dated 11/21/2024 indicated that R1 along with multiple other residents had symptoms of norovirus. However, a review of other incident reports does not indicate that R1 was positive from other previous outbreaks in 2024 and 2025. Interviews with S7 and S9 indicated that when there is an infectious outbreak in the facility, Personal Protective Equipment (PPE) is worn before going inside a residents’ room. A review of email correspondence from ED to LPA indicates that when there is an outbreak, the ED will report to Local Public Health (LPH) of the outbreak and get recommendations on what to do. Interview with 5 of 5 residents revealed that staff have been observed to be using PPE supplies before. In addition, interview with R2 indicated that staff were using gloves while assisting with their showers. Based on interviews and observations conducted, the above allegation that staff did not implement proper infection control practices 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 allegations are unsubstantiated. Allegation: Staff exposed residents to a hazardous chemicals. It was alleged that staff exposed residents to a hazardous chemical. On 01/30/2026, LPA P. Manalo conducted a tour around the facility and did not observe any hazardous chemicals. On 04/28/2026, LPA P. Manalo and K. Nguyen did not observe any foul odor or hazardous chemicals being used throughout the facility. Continue to LIC9099-C... Continued from LIC9099-C... Interview with ED, S3, and S4 all indicated that R1 has their own cleaning products that housekeepers will use to clean R1’s room. Furthermore, S3 stated that housekeepers will dilute the cleaning products with water before using. 6 of 9 residents interviewed all indicated that they do not have any issues with the type of cleaning chemicals that are used. Interview with S7 revealed that when housekeeping is scheduled for that day, S7 will open R1’s windows and bring R1 down to the common area. S7 stated that by the time R1 is returned to R1’s room, there is no smell. Furthermore, interview with R1 revealed that the facility uses the cleaning products in R1’s room for cleaning. Based on interviews and observations conducted, the above allegation that staff exposed residents to a hazardous chemical 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 allegations are unsubstantiated. No deficiencies cited. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, May 7, 2026 · control 15-AS-20260123080421

Allegation investigated: Facility mismanaging residents medications

On 4/20/2026 at 8:30 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct the initial 10-day investigation and deliver findings for the above allegation. LPA met with Executive Director, Gianni Amari and explained the purpose of the visit. During the course of the investigation, the LPA reviewed R1, R2, R3, and R4's care plans, medication addmission record (MAR), medication log, medication notes, and physicians orders. Report continues on LIC 9099-C Unsubstantiated On the allegation "Facility mismanaging residents medications" it was observed that R1-R4 are all on medication assistance and have their medications managed by the facility. A review of the MAR showed that all medications have been administered according to the physicians orders. LPA interviewed the med-tech on duty on how they work with residents who's medications require them to be taken prior to meals. Med-tech stated that they advise those residents to wait in their room for med-techs to give the meds or meet the residents in dining. LPA also observed in the MAR when residents dosages have been changed and it aligned with physicians orders and medications observed in the med cart. LPA was unable to identify a resident who's medications are being mismanaged and that all medications administered are of the proper dosage and proper time therefore the allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 20, 2026 · control 15-AS-20260410150300

Type of visit: Case Management - Other

On 04/02/2026, Licensing Program Analyst (LPA) P.Manalo conducted a visit to follow up on the status of the over capacity from the case management visit conducted on 01/14/2026 and case management visit on 03/04/2026. LPA met with Executive Director, Gianni Amari and explained the purpose of the visit. On 01/14/2026, the facility was over capacity with a census of 130 and on 03/04/2026 with a census of 132. The original plan of correction was the facility to request a capacity increase. The facility no longer wanted to proceed for a capacity increase and the plan of correction was changed to relocate residents to be within capacity due on 03/13/2026. On 03/13/2026, LPA received an email from Amari that their census is back in compliance. During the visit, LPA reviewed the Resident Roster to confirm the facility's census is 128. No deficiencies cited. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 2, 2026

Type of visit: Case Management - Other

On 03/04/2026 at 4:35 PM, Licensing Program Analysts (LPA) P.Manalo arrived unannounced to conduct a case management visit. LPA met with Executive Director, Gianni Amari, and explained the purpose of the visit. While LPA was leaving the building, LPA observed the main lobby ceiling leaking by the receptionist area. LPA requested for Executive Director to send a plan of what the facility will do in regards to the repair of the leak and the reassurance of resident's safety. The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency and/or repeat deficiency within a 12-month period may result in civil penalty. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 4, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Mar 13, 2026

87303(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by having a leak in the main lobby by the receptionist area which poses a potential safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 4, 2026

Plan of correction: The Executive Director agrees with the facility to come up with a plan regarding the leak and the reassurance of residents’ safety. Additionally, the facility will send proof of correction of the leak fixed.

Type of visit: Case Management - Other

On 03/04/2026 at 3:00 PM, Licensing Program Analyst (LPA) P.Manalo arrived unannounced to conduct a case management visit. LPA met with Executive Director, Gianni Amari and observed during the visit that the facility is over capacity. The facility capacity is 128 and the facility census is 132 While LPA was at the facility for another visit, LPA observed the following deficiency: LPA observed that the facility is over capacity. The facility capacity is 128 and the facility census is 132 residents. However, LPA and ED discussed on 02/27/2026 for an extension so that the facility can relocate residents for facility to comply. Corrections are due on 03/13/2026 and LPA will return to verify at a later time. No deficiencies cited. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 4, 2026

Type of visit: Case Management - Other

On 02/05/2026 at 12:15 PM, Licensing Program Analyst (LPA) P. Manalo arrived unannounced to conduct a case management visit. LPA met with Executive Director, Gianni Amari, and explained the purpose of the visit. While LPA was at the facility for another visit, LPA observed the following deficiency: LPA observed that there are 13 residents on hospice and the facility is only approved for 6. The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency and/or repeat deficiency within a 12-month period may result in civil penalty. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Feb 5, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87632(a) · Plan of correction due date: Feb 20, 2026

87632(a) Hospice Care Waiver (a) In order accept or retain terminally ill residents and permit them to receive care from a hospice agency, the licensee shall have obtained a facility hospice care waiver from the Department... This requirement is not met as evienced by Based on observation and interview, the licensee did not comply with the section cited above by having a total of 13 residents on hospice while the facility is only approved for 6 which poses a potential safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 5, 2026

Plan of correction: By POC date, Executive Director will submit to CCLD a request for additional hospice waivers.

Type of visit: Case Management - Incident

On 01/3/2026 at 3:00 PM, Licensing Program Analyst (LPA) P.Manalo conducted an unannounced Case Management visit regarding a self-reported death report. The facility sent in a death report on 01/14/2026. LPA met with Executive Director (ED), Gianni Amari, and explained the purpose of the visit. Death Report (LIC624A) indicated that on 01/07/2026, R1's home health nurse observed R1 unresponsive and slow breathing. Death report indicated that the cause of death is unknown. During the visit, LPA reviewed facility’s incident report/ communication log, physician’s report, admission agreement, Resident Health Identification Information, progress notes, physician notes, home health care visit forms, and R1's service plan. LPA interviewed ED and S1. Interview with ED revealed that R1 had a wound and was referred to home health services. Interview with both ED and S1 indicated that R1 was diagnosed with a stage III wound per home health nurse documentation LPA will be requesting for a death certificate. LPA may return at a later time. The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiency by POC date may result in additional Civil Penalties. Exit interview conducted, Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Jan 30, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87615(a)(1) · Plan of correction due date: Feb 13, 2026

87615(a)(1) (a) Persons who require health services for or have a health condition including...shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above when facility retained a resident with a stage III pressure wound which posed a potential health risk to persons in care.the state’s words, verbatim · CDSS document, Jan 30, 2026

Plan of correction: The Executive Director agrees to have an in-service regarding prohibited conditions and send proof to CCLD by POC date.

Type of visit: Case Management - Other

On 01/30/2026 at 3:30 PM, Licensing Program Analyst (LPA) P. Manalo arrived unannounced to conduct a case management visit. LPA met with Executive Director, Gianni Amari. While LPA was at the facility for another visit, LPA observed the following deficiencies: Starting at 11:06 AM, LPA observed vacuum in the hallway near a resident's room. At 11:11 AM, LPA observed on the second floor in one of the hallway a bed frame, bed mattress, and portraits. At 12:22 PM, LPA observed hoyer left near Room #333. At 11:08 AM, LPA observed two scissors in R1's room. The deficiencies was observed (see LIC 809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report, civil penalty, and appeal rights provided.the state’s words, verbatim · CDSS document, Jan 30, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Jan 31, 2026

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects...locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Based on observation and record review, the licensee did not comply with the section above by having two scissors unlocked in R1's room with a dementia diagnosis which poses an immediate safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 30, 2026

Plan of correction: By POC date, the Executive Director agrees to remove the scissors, lock it, and send proof to CCLD. Moving forward, the Executive Director agrees to review the physician reports of all the residents to ensure that the specific items are not in the residents' rooms.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Feb 6, 2026

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: The licensee did not comply with the section cited above when the licensee had items such as hoyer lifts, bed frame, bed mattress, portraits, and vacuum which poses a potential safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 30, 2026

Plan of correction: The Executive Director agrees to remove the items, ensuring, and addressing to staff that no items should be left in the hallways. Proof of correction will be sent to CCLD by POC date.

Type of visit: Required - 1 Year

On 01/14/2026 at 08:50 AM, Licensing Program Analysts (LPAs) P. Manalo and K. Nguyen arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Executive Director, Gianni Amari, and explained the purpose of the visit. LPAs toured the facility inside and out including but not limited to residents' apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPAs observe lighting in all rooms is adequate for the comfort and safety of the residents. Hallway temperature was maintained at 75 degrees F. The hot water temperature in a sample of residents’ bathroom were measured at 105.8,105,105, 105, and 105 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats and non-skid shower pan. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Fire Inspection was last conducted on 08/06/2025 from the fire department. Fire extinguisher was last serviced on 02/11/2025. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 2/17/2025. At 12:21 PM, LPAs reviewed 7 residents records. At 12:48 PM, LPAs reviewed 6 staff records and 5 of 6 have current first aid training and 5 of 6 associated with the facility. At 10:30 AM, LPA reviewed a sample of resident’s medications. Continue to LIC802-C... Continue from LIC809... THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT: At 10:30 AM, LPAs observed that the facility did not have 4 of R1’s PRN medications. At 10:45 AM, LPAs observed hammer, wrench, Antacids Tablets, Nystatin Powder, and Cortizone in R3’s room and unlocked Method All-Purpose Cleaning Wipes, Clorox Spray, and Airborne in the activities closet At 11:07 AM, LPAs observed multiple food items such as Greek Nonfat yogurt with a best buy date of 10/08/2025, sauce with best buy date 09/30/2025, Chipotle Southwest with a best buy date of 04/22/2022, smoked guada best buy date of 08/29/2025, etc. At 12:00 PM, LPAs observed the emergency food supply in the same storage room as paint, lighter fluid, and other debris. At 12:30 PM, record review revealed that R3, R5, R6 and R7’s does not have an updated Physician’s Report (LIC602A) At 12:30 PM, LPAs observed that S4 is not associated with the facility. At 2:58 PM, LPA observed that the staff files are incomplete. The Facility was 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 with Executive Director. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Jan 14, 2026

The state marks this report as 8 pages; the online copy we transcribed has 7. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

On 01/14/2026 at 4:05 PM, Licensing Program Analysts (LPAs) P.Manalo and K. Nguyen arrived unannounced to conduct a case management visit. LPA met with Executive Director, Gianni Amari. observed during the annual inspection that the facility is over capacity. The facility capacity is 128 and the facility census is 130 residents. While LPAs were at the facility for another visit, LPAs observed the following deficiency: LPAs observed during the annual inspection that the facility is over capacity. The facility capacity is 128 and the facility census is 130 residents. Civil penalty of $500 is being assessed. The deficiency was observed (see LIC 809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of this report, civil penalty, and appeal rights provided.the state’s words, verbatim · CDSS document, Jan 14, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a) · Plan of correction due date: Jan 15, 2026

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal... This requirement is not met as evidenced by: Based on interview, the licensee did not comply with the section cited above by having a over capacity of 130 residents which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 14, 2026

Plan of correction: 1) Executive Director will also notify fire department within 24 hours of the over capacity census and send proof to CCLD. 2)Executive Director has agreed to create a plan to address the over capacity issue and submit the written plan to CCLD by 01/23/2026.

Type of visit: Case Management - Incident

On 11/19/2025 at 2:00 PM, Licensing Program Analyst (LPA) P.Manalo conducted an unannounced Case Management visit regarding a self-reported death report. The facility sent in a death report on 11/13/2025. LPA met with Executive Director (ED), Gianni Amari, and explained the purpose of the visit. Death Report (LIC624A) indicated that on 10/28/2025, Resident 1 (R1) was preparing for bed with the assistance of Staff 1 (S1). During middle of conversation, R1 began to shake and became unresponsive. 911 was contacted and R1 was transferred to the hospital. On 10/29/2025, R1 approximately passed away at 1:00 AM. During the visit, LPA reviewed facility’s incident report/ communication log, physician’s report, staff schedule, R1's service plan. LPA interviewed S1 and ED. Interview with S1 and ED revealed that R1 was alert before the paramedics came and as R1 was getting transferred to the hospital. LPA will be requesting for a death certificate. LPA may return at a later time. No deficiency cited during today’s visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 19, 2025

Type of visit: Case Management - Incident

On 11/12/2025 at 1:20 PM, Licensing Program Analyst (LPA) P.Manalo conducted an unannounced Case Management visit regarding a self-reported incident. The facility sent in an incident report on 10/21/2025 regarding R1's fracture. LPA met with Executive Director, Gianni Amari, and explained the purpose of the visit. LPA P.Manalo received a self-reported incident report from facility that indicated Resident 1 (R1) had unwitnessed fall on 10/12/2025. R1 was sent to the hospital and was treated for a clavicle fracture. During the visit, LPA reviewed R1's Service Plan dated 05/31/2025, 10/17/2025, and 10/29/2025, Physician Reports, and After Visit Summary. A review of R1's Physician Report dated 10/30/2025 revealed that R1 has a diagnosis of osteoporosis. LPA requested for facility to send the full after-visit summary by 11/21/2025. No deficiencies cited during visit. Exit interview was conducted with Amari and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 12, 2025

Type of visit: Case Management - Other

On 11/12/2025 at 2:30 PM, Licensing Program Analyst (LPA) P.Manalo conducted an unannounced Case Management visit. While LPA was at the facility for another case management, LPA observed the following: On 10/21/2025, CCLD received an incident report of Resident 1 (R1) who sustained a fracture on 10/12/2025. Facility failed to report as required. The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency and/or repeat deficiency within a 12-month period may result in civil penalty. Exit interview conducted with Amari. Appeal Rights, LIC421FC, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 12, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Nov 26, 2025

87211(a)(1) Reporting Requirements A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events... This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above by not sending R1's incident report to the department within the seven day timeframe which posed a safety risk to persons in care.the state’s words, verbatim · CDSS document, Nov 12, 2025

Plan of correction: The Executive Director agrees to review and self-certify the regulation with staff. Proof of correction will be sent to CCLD by POC date.

Type of visit: Case Management - Incident

On 08/18/2025 at 3:05 PM, Licensing Program Analysts (LPAs) P.Manalo and and K. Nguyen conducted an unannounced Case Management visit regarding a self-reported incident. LPAs met with Executive Director, Gianni Armari, and explained the purpose of the visit. Executive Director self-reported an incident that involved resident who experienced financial theft by staff member. Executive Director notified the Police Department and the Ombudsman. The facility also conducted an internal investigation and placed the staff on administrative leave. No deficiencies cited during the visit. Exit interview conducted and a copy of this report is provided.the state’s words, verbatim · CDSS document, Aug 18, 2025

Type of visit: Case Management - Incident

On 08/18/2025 at xx:xx PM, Licensing Program Analysts (LPAs) P.Manalo and and K. Nguyen conducted an unannounced Case Management visit regarding a self-reported incident. LPAs met with Executive Director, Gianni Armari, and explained the purpose of the visit. The incident reported involved a resident who experienced financial theft by a third party home care agency. Executive Director stated that the police department has been notified and the local ombudsman. No deficiencies cited during the visit. Exit interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 18, 2025

Type of visit: Case Management - Other

On 08/18/2025 at 2:00 PM, Licensing Program Analysts (LPAs) P.Manalo and K.Nguyen arrived unannounced to conduct a case management visit. LPA met with Executive Director, Gianni Amari, and explained the purpose of the visit. While LPAs was at the facility for another visit, LPAs observed the main lobby ceiling leaking in 4 different areas. LPAs observed two resident rooms that was affected of the leak. LPAs requested for Executive Director to send a plan of what the facility will do in regards to the repair of the leak and the reassurance of resident's safety. Exit interview conducted and A copy of this report provided.the state’s words, verbatim · CDSS document, Aug 18, 2025

Allegation investigated: Staff do not report incidents to appropriate parties

On 08/05/2025 at 9:10 AM, Licensing Program Analysts (LPAs) P. Manalo and K. Nguyen arrived unannounced to gather additional information, conducted interviews, and deliver the findings on the above allegation. During the course of the investigation, LPA P. Manalo interviewed Executive Director (ED), Reporting Party (RP), Residents, Staff, and Witness. LPAs obtained the following documents such as Admission Agreement, Resident Daily Log, Resident Service Plan dated 03/09/2025, Email Correspondence between Resident 1’s (R1’s) RP and staff members, Family Care Conference dated 04/03/2025, Medication Administration Report (MAR), Medication Verification, Resident Roster, R1’s Call Log from 04/23/2025 to 04/29/2025, Resident Continence Care Log, Carlton HSE Results dated 03/09/2025, Internal Incident Report dated 03/09/2025 and 04/23/2025, Physician Report dated 10/02/2023, Carlton’s Invoice, Service Plan dated 02/04/2025, Staff Schedule, and Staff Roster. Continue to LIC9099-C... Substantiated Continue from LIC9099... LPAs P. Manalo and K. Nguyen conducted interviews with 4 residents and 4 staff. Allegation: Staff do not report incidents to appropriate parties It was alleged that staff do not report incidents to appropriate parties. A review of R1’s Resident Daily Log dated 03/09/2025 and Internal Incident Report dated 03/09/2025 and 04/23/2025 revealed that R1 had multiple unwitnessed falls. Falls were made aware to the responsible parties, however, were not reported to the licensing department. Based on interviews conducted with S2, S2 stated that incident reports will only be reported to the licensing department if the resident was sent to the hospital or had any serious injury due to previous training from the facility. Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D. Exit interview conducted. A copy of this report and appeal rights provided. Continue from LIC9099-A... LPAs P. Manalo and K. Nguyen conducted interviews with 4 residents and 4 staff. Allegation: Staff do not ensure that resident's incontinence needs are met It was alleged that staff do not ensure that resident’s incontinent needs are met. A review of Resident’s Continence Care Services dated 04/22/2025 to 04/30/2025 showed that R1 received continence care every 2 hours. However, interviews with S3, S5, S6, and S7 stated that there are times when R1 would refuse continence care from staff. Facility’s invoice with R1’s responsible party revealed that there is a service charge pertaining to R1’s continence care from March 2025 to May 2025. Progress Notes from the Resident Daily Log also showed that S5 assisted R1 with continence care on 03/19/2025 and 03/26/2025. Allegation: Staff do not assist resident with ambulation It was alleged that staff do not assist resident with ambulation. Interviews with ED, S1, S3, S4, and S5 stated that R1 did not have escort services included in their Service Plan, however, staff will still assist R1 with escorting services to the dining hall when needed. Record review of the Resident Daily Log had progress notes dated 03/19/2025, 03/26/2025, and 04/24/2025 showing that R1 was provided escorted services by staff to the dining hall. Allegation: Staff do not monitor resident for change in condition It was alleged that staff do not monitor resident for change in condition. A record review of the Family Care Conference Progress Detail dated 04/03/2025 showed that the facility conducted a meeting with the responsible party regarding some concerns with R1’s decline of health condition. The conference included speaking with the responsible party regarding the R1’s assessment and updating R1’s service plan. Continue to LIC9099-C... Continue from LIC9099-C... Allegation: Staff do not communicate with responsible party regarding resident's care It was alleged that staff do not communicate with the responsible party regarding resident's care. Based on interviews conducted with S2, S2 stated that most of the communication between the facility and R1’s responsible party was conducted via phone call and email. Record review of text communication correspondence dated between 03/26/2025 to 03/27/2025 showed that staff communicated with R1’s responsible parties via text regarding R1’s care. Record review of email communication between R1’s responsible parties and the facility revealed that the facility communicated about R1’s care plan and continence care between September 2024 and October 2024. A record review of the Family Care Conference Progress Detail dated 04/03/2025 indicated that the facility and family had a meeting regarding R1’s care and the facility’s plan on providing that care to R1. Allegation: Staff handles resident in a rough manner It was alleged that Staff handles resident in a rough manner. Interviews with 4 of 4 residents stated that staff are handling them with care when providing services to the residents and have not observed or heard of any staff being rude to the residents. R2 indicated that when staff are assisting R2 with ADLs, R2 has not had any negative encounter or experiences with staff. Based on interviews and record reviews conducted, the above allegations are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. There is no deficiency noted. Exit interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 5, 2025 · control 15-AS-20250429090259

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Aug 19, 2025

87211(a)(1) Reporting Requirements (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below... This requirement is not met as evidenced by: The licensee did not comply with the section cited above by not reporting to the licensing department of any falls that R1 had at the facility which posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 5, 2025

Plan of correction: The Executive Director agrees to conduct an in-service regarding reporting requirements with all staff and self-certification of the regulation. Plan of correction will be sent to CCLD by POC date.

Type of visit: Case Management - Incident

On 04/02/2025 at 1:25 PM, Licensing Program Analyst (LPA) P.Manalo arrived unannounced to conduct a case management visit in regards to death report received on 03/29/2025. LPAs met with Executive Director, Gianni Amari, and explained the purpose of the visit. Death Report indicated that R1 was found unresponsive in the bathroom and first responders pronounced R1 dead at around 8:30 A.M. LPA obtained Service Plan Report, Carlton AL HSE Report, and 2022 Physician's Report. LPA is requesting for any recent Physician's Report to be sent to CCLD by 04/04/2025. LPA is also requesting for Pendent Report from 03/23/2025, 03/24/2025, Services Provided Report, and Care Notes by 04/10/2025. Executive Director will reach out and obtain a death certificate. Executive Director will notify LPA once obtained. LPA may return at a later time. No deficiencies are being cited on this date. Exit interview conducted. A copy of this report provided.the state’s words, verbatim · CDSS document, Apr 2, 2025

Allegation investigated: Lack of Supervision

On 1/31/2025 at 12:15PM, Licensing Program Analysts (LPAs) G. Luk and P. Manalo arrived unannounced to conduct a complaint investigation and deliver findings regarding the allegation above. LPAs met with Executive Director, Meghian Geul and informed her of the reason for the visit. During the course of investigation, LPAs interviewed 2 residents, staff, witness, and complainant. LPAs reviewed and obtained documents including physician's report, care plan, and facility notes. Interview with staff and witness revealed that staff (S2) accompanied R1 to another resident's room. R1 was discovered missing by family member and facility staff was not aware. Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D. Exit interview conducted. A copy of this report and appeal rights provided. Substantiatedthe state’s words, verbatim · CDSS document, Jan 31, 2025 · control 15-AS-20250127133155

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Feb 7, 2025

Additional Personal Rights of Residents in Privately Operated Facilities. To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidence by: Based on investigation, licensee did not comply with section cited above by escorting R1 to the incorrect room and unaware R1's whereabouts which poses a potential health and safety risk to the persons in care.the state’s words, verbatim · CDSS document, Jan 31, 2025

Plan of correction: Executive Director has agreed to conduct training for staff regarding escorting residents and submit staff sign in sheet with training materials to CCLD by POC date.

Type of visit: Required - 1 Year

On 01/08/2025 at 9:30 AM, Licensing Program Analysts (LPAs) P. Manalo and K. Nguyen arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Executive Director, Meghian Geul, and explained the purpose of the visit. The facility’s fire clearance was approved for capacity of 128 residents and 77 of those residents may be non-ambulatory. The facility is also approved for hospice waivers of 6. LPAs toured the facility inside and out including but not limited to 4 residents' apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPAs observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 69 degrees F. The hot water temperature in a sample of residents’ shared bathroom were measured at 109.2, 115.5, 108.2 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats/ non-skid shower pan. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 02/08/2024 all around the facility. Emergency disaster drill was last conducted on 12/30/2024. At 01:16 PM, LPAs reviewed 6 residents records. At 11:30 AM, LPAs reviewed 6 staff records and 6 of 6 have current first aid training and associated to the facility. At 3:00 PM, LPAs reviewed two sample of resident’s medications. Continue from LIC 809-C... Continue form LIC809... Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 01/22/2025: LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Liability Insurance THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT: At 10:20 AM, LPAs observed a knife in R2's room. At 10:33 AM, LPAs observed Lysol spray and multiple bottles of dish soap in the R3's bathroom. At 10:37 AM, LPAs observed cleaning supplies such as Lysol spray and The Pink Stuff. At 10:38 AM, LPAs observed prescribed solution in R1's bathroom. At 10:45 AM, LPAs observed that the second floor, third floor, and kitchen did not have a full complete first aid kit. At 3:15 PM, LPAs observed that R2 did not have his PRN medication in the Med Tech room. At 3:20 PM, LPAs observed R2 does not have a doctor's order for a medication that was found on his medication bin that labeled R2's room number. The Facility was 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 with Executive Director. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Jan 8, 2025

Type of visit: Case Management - Incident

On 01/08/2025 at 4:30 PM, Licensing Program Analysts (LPAs) P.Manalo and K. Nguyen conducted an unannounced Case Management visit regarding a self-reported incident report abuse that occurred on 12/30/2024. LPAs met with Executive Director, Meghian Geul, and explained the purpose of the visit. LPAs interviewed Executive Director and obtained the SOC341. Executive Director stated facility reported to Ombudsmen, APS, and CCLD. Resident is no longer residing at facility as of 12/31/2024. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jan 8, 2025

Type of visit: Case Management - Annual Continuation

On 4/24/2024 at 10:00AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct Case Management - Annual Continuation. LPA met with Executive Director, Meghian Geul and explained the purpose of the visit. During visit, LPA reviewed 7 residents' files and 7 staff files. LPA observed resident's files were complete and staff files were complete. Staff have current first aid and CPR training. LPA observed staff completed training which includes dementia, food service, resident rights, medication, ADL (Activities of Daily Living) care, and other topics. Last fire drill was conducted on 3/28/2024. LPA reviewed a sample of resident's medications at around 3:30PM. LPA interviewed 5 residents and 5 staff starting at 2:00PM. No deficiencies are being cited on this date. Exit interview conducted. A copy of this report were provided.the state’s words, verbatim · CDSS document, Apr 24, 2024

Type of visit: Required - 1 Year

On 1/30/2024 at 1:50PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with Executive Director, Meghian Geul. The facility’s fire clearance was approved for 128 residents of which 77 residents may be non-ambulatory and 6 residents may be under hospice care. LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, activity rooms, kitchen, common areas, and outdoor area. Centrally stored medications were locked in medication carts located in med rooms. Smoke detectors were interconnected with sprinkler system. Carbon monoxide detectors were observed. Fire extinguishers were observed to be full and last serviced on 3/2/2023. One week of nonperishable and 2-day of perishable food supplies were available. Facility orders food twice a week. Comfortable temperature was maintained inside the facility. Hot water temperature was measured at 112.1 degrees F in a resident's bathroom. Grab bars for each toilet and shower were installed. Non-skid mats were observed. There were adequate lights in each room. Resident rooms were observed to be cleaned and fully furnished. Indoor and outdoor passages were free of obstruction. LPA will return at a later time to complete the inspection. At 2:32PM, LPA observed lysol sprays stored with food supplies in the kitchen and pantry area. Staff removed the lysol sprays and stored in an area separate from the food items. The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 30, 2024

Allegation investigated: Residents were molested while in care Resident sustained injury while in care Staff did not seek medical attention for the resident

On 12/11/2023 at 9:55 AM, Licensing Program Analyst P Watson arrived unannounced deliver findings for the above allegations. LPA met with Resident Liaison, Mar Brown and Care Manager, Yaritza Yanez and explain the purpose of the visit During the course of the investigation, LPA L. Fici requested and obtained the facilities current staff schedule, personnel report (LIC 500), facility sketch, most recent physicians report, evaluation and service plan, admission agreements, any unusual Incident Reports (LIC 624) for October 2023, case notes for October 2023, Hospice notes, home health notes, medication log, and emergency and identification information. In addition, current staffing roster with contact information. Report continues on 9099 C Unsubstantiated It was alleged that, Residents were molested while in care. Based on interview with resident (R1), R1 stated that two men came into their room at night to offer them water and a diaper change, R1 felt uncomfortable by the two men and expressed to them that they did not want the two men to come into their room anymore. R1 learned that those two men were R2 and R2’s brother, and not facility staff. R1 did not disclose abuse of any kind by facility staff. It was alleged that, Resident sustained injury while in care. Based on record review, staff (S1) tried to care for R2, but was unable to due to R1 not allowing S1 to render care to R2. R1 pulled on S1 and cut their finger, S1 gave R1 a bandage and suggested they be evaluated due to their behavior and injury. It was alleged that, Staff did not seek medical attention for the resident. Based on record review, S1 provided first aid to R1 and evaluated them when they injured themselves, based on the injury facility staff did not call EMS for R1. Based on interviews and record review, although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Dec 11, 2023 · control 15-AS-20231010162801

Type of visit: Case Management - Health Checks

On 10/13/23, at 11:05 AM, Licensing Program Analyst (LPA) L. Fici conducted a Health & Safety inspection as a result of a priority 1 complaint. LPA met with Geul, Meghian E, Administrator (ADM) and explained the purpose of the visit. LPA toured facility with ADM, including but not limited to the bedrooms, bathrooms, common area, kitchen, and outdoor area. Hot water temperature was measured at 116.4 Degrees F in residents bathroom on the fourth floor. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. The kitchen refrigerators temperature was observed at 40 Degrees F and the freezer was at 0 Degrees F. Resident's medications were kept locked and inaccessible to residents. Smoke detectors are interconnected with the sprinkler system. Carbon monoxide detector was observed and operational. First-aid kit was complete. Fire extinguisher was observed to be full and last serviced on 3/2/2023. There are no accessible bodies of water observed. Indoor and outdoor passageways are free of obstruction. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 13, 2023