Carlton Plaza of San Leandro

Type of visit: Case Management - Other

On 7/16/2026 at PM, Licensing Program Analyst (LPA) Y. Brown arrived unannounced to conduct a Case Management visit to discuss food service and staffing plans. LPA met with Executive Director (ED) Angela Turin, and explained the purpose of the visit. During the visit, LPA and ED discussed ways on how the facility can implement a plan to minimize the wait times for the residents food service. LPA and ED also discussed implementing a staffing plan to ensure sufficient staff is at the facility at all times. LPA requested an updated LIC500 (Personnel Report). LPA may return at a later time. No deficiency cited. Exit interview conducted with Angela and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 16, 2026

Type of visit: Case Management - Incident

On 4/29/2026 at 10:30 AM, Licensing Program Analyst (LPA) Y. Brown conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 4/24/2026. LPA met with Angela Turin, Executive Director and explained the purpose of the visit. S1 submitted an incident report that stated that R1 ingested a small amount of Mckesson Perineal & Skin Cleanser fluid. The incident report states that the incident happened on 4/20/2026 at around 10:51 pm. S1 stated that S2 was conducting a routine visit in R1's room when they observed R1 removing the cleanser down her mouth and S2 observed R1 having a facial expression that appeared to be a "bad taste." S1 stated S3 called Poison Control around 10:55 pm and poison control told S3 to give R1 water and to monitor R1. S1 stated that R1 was monitored throughout the night by S3 and the hospice nurse and resident remained at baseline. S1 stated that R1 was also monitored the following day and stayed at baseline. S1 stated that they contacted the responsible parties. S1 stated that staff removed all of the hazardous items from R1's room and notified hospice. R1 was not resulted in any ill side effects due to this incident. LPA interviewed Staff (S1). LPA was unable to interview R1 at this time since R1 was sleeping during the visit. LPA obtained and reviewed the following documents: R1's appraisal needs and services plan, LIC602 (Physicians report), and MAR (Medication Administration Record)-March & April. LPA also reviewed R1's hospice care plan. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted with Angela. A copy of the appeal rights and this report was provided.the state’s words, verbatim · CDSS document, Apr 29, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Apr 30, 2026

87309 Storage Space and Access (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items... This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by having McKesson Perineal & Skin Cleanser fluid unlocked and accessible to R1's room which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 29, 2026

Plan of correction: Executive Director (ED) conducted an in-service training regarding hazardous items with staff. ED created a list of residents who can and cannot have access to Hazardous/Hygiene Products/Items. ED conducted an immediate room search of every unit and removed all unlocked hazardous products from units for 24 hours. Staff reviewed all LIC602s and put the products back in units that are able to have access to the products. Locks were installed in every resident unit to store hazardous products. DEFICIENCY CLEARED DURING VISIT

Allegation investigated: Staff physically abused resident resulting in bruises. Staff financially abused resident. Resident's rooms are malodorous. Staff do not ensure food is properly disposed.

On 4/21/2026 at 10:00 AM, Licensing Program Analysts (LPAs) A. Gomez and Y. Brown arrived unannounced to deliver findings for the above allegations. LPA met with Executive Director, Angie Turin and explained the purpose of the visit. During course of the investigation, the Department conducted interviews with facility staff, witnesses and complainant. Documents including but not limited to: Residents Admission agreements, physician’s reports, care plans, medication logs, incident reports, photos of residents, discharge notes, and R1’s Death Certificate were reviewed and or obtained. Report continues on LIC9099-C Substantiated Pg 2 On the allegation of staff physically abused resident resulting in bruises LPA’s conducted interviews with residents, staff, witnesses, and obtained photos. On 3/21/2025 LPA’s interviewed R2 Who stated that sometimes when staff bathe them, they are too rough. LPA‘s interviewed W6 who states that they noticed bruising on R2 when they came to visit them. W6 states that when they asked R2 what happened they stated that W3 had left the bruises because they were being too rough while bathing them. W6 states that they were informed the bruises were a result of W3 grabbing R2 too tightly. W6 states that a police report was not made because W3 had already been fired. LPA‘s obtained photographs that showed R2 had sustained bruising on both forearms. LPAs observed that the bruising is consistent with being grabbed, therefore, the allegation of staff physically abused resident resulting in bruises is substantiated. On the allegation of staff financially abused resident the department conducted interviews, obtained documentation, and conducted a financial audit. During the investigation LPA’s interviewed R4 who stated that in late 2024 they were being financially abused. LPA’s interviewed S2 through S12. S1, S2, S11, and W1 stated that they had all heard of a resident having been financially abused by the previous Resident Liaison (W2) however they were not sure if it was true. LPA interviewed the previous executive director who stated that they had reported possible financial abuse to the San Leandro police department, but nothing further came of the investigation. LPA‘s requested potential documentation of financial abuse on 3/21/2025 . Previous Executive Director stated that they did not have record of any proof of financial abuse. On 6/12/2025 LPA’s return to the facility and again requested documentation of financial abuse and the executive Director was able to produce a document stating the name of employee of former resident liaison (W2) on an official bank document for R4. LPA’s then requested a financial audit of R4’s bank accounts on 8/06/2025. The financial audit revealed that W2 had been getting direct transfers from R4’s bank account to their personal account. Therefore, the allegation of staff financially abused resident is substantiated. Report Continues on LIC9099-C Pg 3 On the allegation residents rooms are malodorous LPA’s toured the facility on 3/21/2025. While touring the facility on 3/21/2025, LPA’s observed on the second floor a strong smell of human urine. LPA’s briefly spoke to a staff member passing by name unknown, who stated that urine is a common odor in that part of the facility. LPA’s were able to locate the odor in R17’s room. LPA observed that R17 utilizes a catheter and that urine was spilling onto the floor. LPA’s interviewed R17 who states that staff do not come to assist in cleaning the urine and that they are charged extra if they need their floors cleaned. During the course of the investigation LPAs also conducted interviews with S1 and S6. S1 states that staff should be cleaning the floors and also S1 stated that rooms are cleaned on an annual schedule however if a resident has an accident on the floor that they need to come down to the front desk to ask for their room to be cleaned. S6 states that they have noticed lingering urine odors before. Therefore, the allegation of resident's rooms are Malodorous is substantiated On the allegation, staff did not ensure food is properly disposed LPA’s toured the facility and made observations. On 8/21/2025 LPA’s observed in R4’s room food with mold and expired in their refrigerator. The food observed was covered in saran wrap, and in dishes provided during tray service. At the time of the Observation, LPA’s observed R4 was bed bound and on full care. LPA‘s interview S1 who stated that R4 was currently receiving tray service and incontinence care. LPAs found through interviews that staff are expected to deliver the trays and then return a few hours later to retrieve the dishes and trays after meal times. LPAs also interviewed S2 and S10 who stated that they have noticed staff not removing trays as required and food leftovers not being disposed of properly. Therefore, the allegation of staff did not ensure food is properly disposed is substantiated. Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. The following deficiencies were observed (see LIC 809D) and 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. Appeal Rights and a copy of this report provided. On the allegation of “Questionable Death” the Department obtained copies of the death report for R1. After a review it was found that R1 passed away from ventricular arrhythmia and coronary artery disease. LPA’s also reviewed R1’s medical records and physicians reports and observed that R1 had related pre-existing conditions. Therefore the allegation of Questionable Death is unsubstantiated On the allegation of “Staff do not ensure residents showering needs are being met” LPAs interviewed R2, R3, R4, R7, and R8 . R2 and R7 both stated that their showering needs are being met. LPAs also reviewed shower logs and care plans. LPAs observed that showers are being provided and care plans are being followed in regards to showering needs therefore the allegation Staff do not ensure resident's showering needs are being met 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 allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 21, 2026 · control 15-AS-20241113154936

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: May 5, 2026

(a)In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (8)To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement was not met as evidence by: Based on interviews and record review, the licensee did not comply with the section cited above in R4 being financially abused by previous staff member (W2) which posed an immediate personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 21, 2026

Plan of correction: By POC date, the facility agrees to conduct 2 hours of training on personal rights and Reporting Requirements with an approved CCLD vendor and send proof of training to CCLD.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87413(a)(2) · Plan of correction due date: May 5, 2026

(a)In each facility:(2)Care and supervision of residents shall be provided without physical or verbal abuse, exploitation or prejudice. This requirement was not met as evidence by: Based on interviews and photos, the licensee did not comply with the section cited above in R2 sustaining bruises on both arms while being showered by W3 which posed an immediate personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 21, 2026

Plan of correction: By POC date, the facility agrees to review personal rights and provide in-service to all staff on proper bathing procedures and provide the training materials to CCLD.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: May 5, 2026

(b)In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3)Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met as evidence by: Based on interviews and observations made by LPAs, the licensee did not comply with the section cited above in R17s room smelling of urine which posed a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 21, 2026

Plan of correction: By POC date, the facility agrees to develop a semi-annual carpet cleaning schedule and provide the rooms and dates that are being cleaned. The facility also agrees to create a plan for the residents known to have incontinence care and provide the time and dates and send these plans to CCLD.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(f) · Plan of correction due date: May 5, 2026

(f)All waste shall be located, stored, and disposed of in a manner that will not transmit communicable diseases or odors, pose a risk to health and safety, or provide a breeding place or food source for insects or rodents. This requirement was not met as evidence by: Based on observations made by LPAs, the licensee did not comply with the section cited above in R4s room having moldy and expired foods while R4 was on full care and bed bound which posed a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 21, 2026

Plan of correction: By POC, the facility agrees to check all of the residents rooms and develop a daily check sheet for staff to ensure that all rooms are free of trays and discarded food by the end of the night midnight and send the sheet to CCLD.

Allegation investigated: The facility broiler is in disrepair, leaving the building without hot water Staff do not ensure resident needs are met

On 12/04/2025 at 10:00AM, Licensing Program Analysts (LPAs) T. Syess-Gibson and Yasamine Brown arrived unannounced to deliver complaint findings for the allegations above. LPAs met with Executive Director, Angela Turin and explained the purpose of the visit. Allegation: The facility broiler is in disrepair, leaving the building without hot water Interviews with staff and residents revealed that the facility’s boiler malfunctioned and burst, leaving the facility without hot water for two (2) days. During this time, residents were unable to take hot showers or baths. Continue on LIC9099C... Substantiated Continued from LIC9099 Allegation: Staff do not ensure resident needs are met Interviews with residents revealed that staff were not making rounds every two (2) hours. Residents also stated during interview, staff only check on them when the call button is pressed or when Alexa is used to contact the front desk for assistance. 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 with Evelyn Jenson. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Dec 4, 2025 · control 15-AS-20250827161242

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Dec 11, 2025

(a) The facility shall be clean, safe, sanitary and in good repair at all times.... This requirement was not met as evidence by: Based on interviews and record review the licensee did not comply with the section cited above in having a malfunctioning broiler which posed a personal rights and potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Dec 4, 2025

Plan of correction: By POC date, facility agrees to read regulation 87303 and send a self certifying email to CCLD.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Dec 11, 2025

(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities,...:(4) To care, supervision, and services...This requirement was not met as evidence by: Based on observation the Licensee did not comply with the section cited above in not having sufficient in numbers to meet the needs of residents care. which poses a personal rights and potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Dec 4, 2025

Plan of correction: By POC date, the facility agrees to implement a plan to ensure staff is sufficient in numbers to meet the needs of residents care.

Type of visit: Case Management - Annual Continuation

On 9/3/2025 at 9:30 am, Licensing Program Analysts (LPAs) Y. Brown and A. Gomez arrived unannounced to conduct the annual continuation that was conducted on 8/21/2025. LPAs met with Executive Director Evelyn Jenson and explained the purpose of the visit. The facility’s fire clearance was approved for one-hundred nineteen (119) total capacity. One-hundred fifteen may be non-ambulatory and eighty-four (84) may be ambulatory residents. Hospice waiver approved for eighteen (18). LPAs toured the facility including but not limited to a random sample of residents’ apartments, bathrooms, multiple activity rooms, kitchen, common area and outside courtyard. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 74 degrees F. LPA's returned to conduct file review. LPAs reviewed five (5) residents records. LPAs reviewed six (6) staff records. MAR was also reviewed. Report continues on LIC809-C THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT: On 8/21/2025 LPA's observed unlocked shed with filled gasoline tank. Personnel records were not readily available upon request and were observed incomplete. On 8/21/2025 LPA's observed that three (3) staff members had expired first aid certification. On 8/21/2025 LPA's observed that the food container lids were not properly placed and stored in the kitchen LPA's observed that R6 appraisal needs and services plans were not updated. On 8/21/2025 LPA's observed that the facilities call buttons were in disrepair LPA's observed that resident records were not readily available upon request and were incomplete. Two (2) technical violations were issued during the visit. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 09/10/2025: LIC 500 Personnel Report LIC 610E Emergency Disaster Plan - Reviewed Current Administrator’s Certificate The following deficiencies were observed (see LIC 809D) and 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. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 3, 2025

Type of visit: Required - 1 Year

On 8/21/2025 at 9:30 am, Licensing Program Analysts (LPAs) Y. Brown and A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Executive Director Evelyn Jenson and explained the purpose of the visit. The facility’s fire clearance was approved for one-hundred nineteen (119) total capacity. One-hundred fifteen may be non-ambulatory and eighty-four (84) may be ambulatory residents. Hospice waiver approved for eighteen (18). LPAs toured the facility including but not limited to a random sample of residents’ apartments, bathrooms, multiple activity rooms, kitchen, common area and outside courtyard. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 74 degrees F. The hot water temperature in a sample of resident bathrooms were measured at 109.1, 109.2, and 110.3, 110.4, and 108.5 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. LPAs reviewed a sample of medication. LPAs will return at a later time to continue Annual Required Inspection. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 21, 2025

Allegation investigated: Staff hit resident

On 3/5/2025 at 12:40pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to deliver complaint findings for the allegation above. LPA met with Jocelynn Ahnstrom, Director of Resident Services and explained the reason for the visit. During the course of the investigation the Department conducted interviews with staff, witnesses, resident, obtained and reviewed records. Allegation: Staff hit resident Based on interview with W1 it was stated she was told by R1 that R1 was hit by a male caregiver (S4) while sleeping. W1 then reported conversation with R1 to facility Continued on LIC9099C. Unsubstantiated Continued from LIC9099. staff. R1 stated during interview that S4 did not say anything just hit her 3xs in the chest. On December 10, 2024, facility staff was interviewed. S2 stated S4 worked the overnight shift through a registry. S2 also stated the appropriate agencies were notified of the allegation. S3 stated S4 had only worked two (2) shifts with the facility. S3 had received positive feedback from other staff when S4 worked the previous shift. S3 stated he immediately removed S4 from the registry database after receiving the allegation. The day following the allegation S3 went to R1’s room. S3 stated there was not any observation of swelling, bruises, or abrasions on R1. S5 stated during interview that the night of the allegation S4 was assigned to R1. S5 also stated R1 is a 2-person assist with toileting, therefore, both (S4 and S5) went into R1’s room that night together to assist R1, which R1 refused. R1 was asleep when they entered the room. S4 stated he was not aware of any allegation towards him during interview. Review of R1’s individual service plan dated November 10, 2024, indicates R1 has a pendent to push in care of an emergency. Based on record review of the San Leandro Police Department report dated November 30, 2024, there was no evidence of injury or in-room or hallway cameras that would have captured any portion of the incident. Based upon the information obtained and the interviews conducted during the investigation, the above allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted and a copy of report was given.the state’s words, verbatim · CDSS document, Mar 5, 2025 · control 15-AS-20241202105003

Allegation investigated: Staff did not seek timely medical attention for a resident

On December, 18, 2024 at 2:00 pm Licensing Program Analyst (LPA) J. Clancy-Czuleger and A. Gomez arrived unannounced to deliver findings on the above allegation. LPA met with Facility Supervisor Evelyn Jensen and explained the purpose of the visit. The Department’s investigation included but was not limited to interviews with current staff, witnesses, residents, and the collection and review of records from the hospital and facility. The facility's incident report indicated Resident (R1) was given the wrong medications at 0845 hours on February 8, 2024, yet the facility called Kaiser’s advice line at 0947 hours. A review of the Kaiser Permanente medical records showed that Falck ambulance was told R1 was given the wrong medications at 1000 hours, and she was not transported to the Emergency Department (ED) until 1057 hours. Staff (S1) interviewed said R1 was given the wrong medications between 0830-0900 hours. Continued on 9099-C... Substantiated ...Continued from 9099 Once S1 realized his error, he reported to front desk after 3-5 minutes. The Licensed Vocational Nurse (S3) responded to monitor R1. Although other measures were attempted to raise R1’s blood pressure, S3 knew it would not drastically help. Further, S3 said she knew R1’s blood pressure would significantly drop and R1’s condition would decline. However, the advice from another nurse (S4) was for S3 to continue monitoring R1 and to call an ambulance only when R1 began showing signs of decline. The preponderance of evidence standard has been met; therefore, the above allegation(s) were found to be substantiated. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. Appeal Rights and a copy of this report provided via email.the state’s words, verbatim · CDSS document, Dec 18, 2024 · control 15-AS-20240501124551

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Dec 30, 2024

The licensee shall ensure that residents are regularly observed for changes...that appropriate assistance is provided when such observation reveals unmet needs….. This requirement is not met as evidenced by… Based on records review and interview, the licensee did not comply with the section cited above by not calling medical attention for the resident until an hour after the error had occurred and did not call for transported until two hours after the error had occurred which posed an health and safety risk to the resident.the state’s words, verbatim · CDSS document, Dec 18, 2024

Plan of correction: By POC date, Administrator states that: 1. Record of the in-service training that was held on emergency calls for residents for staff, and any updated training 2. Administrator will read the regulation and submit self-certification stating understanding Proof of correction will be sent to CCLD by POC date

Type of visit: POC

On 12/18/2024 at 2:00PM Licensing Program Analysts (LPAs) A Gomez J Clancy-Czuleger arrived unannounced to conduct a POC visit in relation to the deficiencies issued on 11/14/2024. LPAs met with Executive Director, Evelyn Jensen and explained the purpose of the visit. The facility is licensed for 199 residents of which 115 may be non-ambulatory. On 11/14/2024 LPA A Gomez conducted a case management visit and cited for the following: 87555(b)(27): On 11/14/2024 LPA observed insects in the kitchen. POC is now clear. 87303(a)(1): On 11/14/2024 LPA observed dirty floors and surfaces in the kitchen. POC is now clear. On 12/18/2024 LPAs observed the following Deficiency: Food is not being properly stored in the kitchen. LPAs observed open raw chicken, uncovered peaches, and other improperly stored foods in the refrigerators. The following deficiencies were observed (see LIC 809D) and 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. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Dec 18, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(9) · Plan of correction due date: Dec 30, 2024

(b)The following...shall apply: (9) Procedures which protect the safety, ...of food shall be observed in food storage, preparation and service. This requirement was not met as evidence by Based on observation the Licensee did not comply with the section cited above with having improperly stored food in the kitchen refridgerators which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 18, 2024

Plan of correction: By POC Facility agrees t oreview the food storage and properly store all improperly stored food in the kitchen and notify CCLD.

Allegation investigated: Third floor of the facility has too many non-ambulatory residents.

On 11/20/24 around 02:00 PM, Licensing Program Analyst(LPA) L.Holmes conducted a 10-day complaint investigation and met with Evelyn Jensen, Executive Director (ED) and toured the facility with Sheila Rodriguez, Sales Director. During the course of the investigation, LPA and S2 toured the facility, the following documents were reviewed with S1: LIC 602, Ambulation Details Report, CCLD's Plan of Correction dated 10/31/24, Alameda County Fire Department Inpection/Review dated 10/25/24, and emails sent to CCLD's Staff Support for a capacity increase. LPA requested the current LIC 500 and current Resident Roster. Allegation: SUBSTANTIATED Third floor of the facility has too many non-ambulatory residents. Continued in LIC9099C... Substantiated ...continued from LIC9099C. Third floor of the facility has too many non-ambulatory residents. LPA and S1 reviewed the LIC602's for fifty-one (51) residents that reside on the third floor, The Ambulation Details Report revealed that there's a today of 8 non-ambulatory residents on the the third floor. The facility has two (2) non-ambulatory residents over the approved capacity of six (6) based on the LIC602s, therefore the allegation is substantiated. An immediate civil penalty of $250 is hereby assessed for a repeat violation. Deficiency is cited from Title 22 California Code of Regulations and listed on 9099D. Failure to submit proof of corrections by plan of correction due dates and any repeat violation within 12 month period may result in civil penalties. Exit interview conducted, Appeal Rights, and a copy of this report provided to ED.the state’s words, verbatim · CDSS document, Nov 20, 2024 · control 15-AS-20241114145918

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87202(a)(1) · Plan of correction due date: Dec 4, 2024

87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by...fire protection services...Prior to accepting or retaining any of the following types of persons...licensee shall...obtain an appropriate fire clearance... (1) Nonambulatory persons. -This requirement is not met as evidenced by: Based in interviews and records reviewed, the facility has 8 non-ambulatory residing on the 3rd floor but only 6 are approved which poses a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 20, 2024

Plan of correction: Licensee to update Resident Roster, Ambulation Details Report and notify Residents/RP's of relocating to a different unit. A 60-day eviction notice is to be approved by CCLD if there is not an agreed resolution by the POC date.

Type of visit: Case Management - Health Checks

On 11/14/2024 at 5:00 PM, Licensing Program Analyst (LPA) A. Gomez conducted a Health & Safety inspection as a result of a priority 1 complaint. LPA met with Executive Director, Evelyn Jensen and explained the purpose of the visit. LPA toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, and outdoor area. Hot water temperature was measured at 107.8 and 107.6 degrees F in random bathrooms. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Refrigerator temperature was observed at 39 degrees F. Resident's medications were kept locked in the med room. Smoke detectors are interconnected with the sprinkler system. Carbon monoxide detector observed. First-aid kit was complete. Fire extinguisher was observed to be full and last serviced on 11/3/2024. There are no accessible bodies of water observed. Indoor and outdoor passageways are free of obstruction. LPA cited for the following: LPA observed small black flying bugs in kitchen area/ food area LPA observed Kitchen floors dirty and sticky. The following deficiencies were observed (see LIC 809D) and 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. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 14, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(27) · Plan of correction due date: Dec 11, 2024

(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of ... insects. This requirement is not met as evidenced by: Based on observation of the kitchen the Facility did not comply with the section above by the kitchen having small flying insects which poses a potential health and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 14, 2024

Plan of correction: By POC date Facility agrees to develop and implement a plan to get rid of bugs and notify CCLD.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(a)(1) · Plan of correction due date: Dec 11, 2024

(a) The facility shall be clean, ... for...residents, employees and visitors.(1)Floor surfaces in ...kitchen areas shall be... clean.... This requirement is not met as evidenced by: Based on observation of the kitchen the Facility did not comply with the section above by the kitchen having a dirty/sticky floor which poses a potential health and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 14, 2024

Plan of correction: By POC date Facility agrees to sanitize and clean kitchen and notify CCLD.

Type of visit: Case Management - Deficiencies

On 10/7/2024 at 3:00 PM, Licensing Program Analysts (LPAs) James Sampair and David Doidge conducted a Case Management - Deficiencies inspection. Upon entry into facility, the LPAs explained the purpose of the visit to Administrator Evelyn Jensen. This visit was prompted by the Licensee's failure to reduce the number of non-ambulatory residents living on the third floor of the facility to 6 in accordance with the fire clearance. The facility was cited for this infraction. Exit interview conducted with Administrator. A copy of this report and the appeal rights were provided to the Administrator.the state’s words, verbatim · CDSS document, Oct 7, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87204(a) · Plan of correction due date: Oct 14, 2024

87204 Limitations - Capacity and Ambulatory Status (a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license . . . This requirement is not met as evidenced by: Based on observation, the Licensee did not comply with the section cited above as 12 and not 6 non-ambulatory residents are living on the third floor of the facility, which poses a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 7, 2024

Plan of correction: On or before the due date, the Licensee shall reduce the number of non-ambulatory residents living on the third floor from 12 to 6 and inform the Department of the reduction.

Type of visit: Required - 1 Year

On 9/16/2024 at 10:30 AM, Licensing Program Analysts (LPAs) David Doidge and James Sampair arrived unannounced to conduct the Required Annual Inspection. Upon entry, LPAs stated the purpose of the visit to Daisy Monteon Executive Assistant at 10:40 AM. LPAs 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 09/01/2024. Temperature in the facility was measured at 74.0 degrees Fahrenheit at 10:51 AM. Water temperature is 112 degrees Fahrenheit. The LPAs observed required postings in the facility, including the Complaint Poster, Ombudsman and Personal Rights posters, and the Theft and Loss Policy. An administrator is on site more than the minimum of 20 hours a week to oversee the proper business operations. 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. One week of nonperishable and 2 days of perishable food supplies were available. Facility orders food twice a week. 1 B-type citation issued. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 16, 2024

Allegation investigated: Facility staff did not provide assistance to resident. Facility staff charged for services not rendered.

On 5/23/2024 at 11:45 AM, Licensing Program Analysts (LPAs) J. Sampair and A. Gharachorloo arrived unannounced to investigate the allegation above. The LPAs informed Executive Director Evelyn Jensen of the reason for the visit. The complaint alleges that facility staff did not provide assistance to resident. Based on a review of facility records, the staff are providing the assistance to resident in accordance with their care plan. The complaint alleges that facility staff charged resident for services not rendered. Based on a review of facility records, the facility staff are rendering escorting services the resident pays for that are in accordance with their care plan. Continues on LIC9099 . . . Unsubstantiated . . . Continued from LIC 9099 Although the allegations may have happened, or are valid, there is not a preponderance of evidence to prove them; therefore, the allegations are UNSUBSTANTIATED. Exit interview conducted with ED. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, May 23, 2024 · control 15-AS-20240516085526

Allegation investigated: Third floor of the facility has too many non-ambulatory residents.

On 5/23/2024 at 11:45 AM, Licensing Program Analysts (LPAs) J. Sampair and A. Gharachorloo arrived unannounced to investigate the allegation above. The LPAs informed Executive Director Evelyn Jensen of the reason for the visit. The complaint alleges that on the 3rd floor of the facility there are too many nonambulatory residents. Based on a review of facility records, the fire clearance is for 6 nonambulatory residents for the third floor, but 19 are currently living on the third floor, which is 13 more than allowed. Continues on LIC9099 . . . Substantiated .... Continued from LIC9099 The complaint 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. Deficiencies are cited per Title 22 California Code of Regulations as listed on the LIC 9099-D. Additionally, due to the severity of the deficiency, a $500.00 immediate civil penalty is assessed today. Exit interview conducted with Executive Director and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 23, 2024 · control 15-AS-20240522100917

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87202(a)(1) · Plan of correction due date: May 30, 2024

87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by … fire protection services … Prior to accepting or retaining any of the following types of persons, … licensee shall … obtain an appropriate fire clearance …. (1) Nonambulatory persons. This requirement is not met as evidenced by: Based on review of facility records, there are 19 nonambulatory residents living on the 3rd floor, but the facility is licensed for a capacity of only 6 nonambulatory residents for the 3rd floor, which poses a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 23, 2024

Plan of correction: On or before the due date, licensee shall submit application to CCLD for an increase of nonambulatory residents to at least accommodate the current number of residents for the 3rd floor of the facility including a sketch of the facility.

Type of visit: Case Management - Health Checks

On 05/03/24 at 9:05AM, Licensing Program Analyst (LPA) J. Clancy-Czuleger conducted an unannounced Health and Safety check due to the department receiving a priority 1 complaint. During the health and safety check, LPA observed a total 143 residents at the facility. LPA toured facility with Executive Director, including but not limited to bedrooms, kitchen, dining rooms, activities rooms, bathroom, outdoor garden and common areas. LPA observed residents comfortable in their surroundings, eating their breakfast meals and relaxing in common areas with family and friends. Residents in care appear to be safe and there are no imminent health/safety concerns on today's date. No deficiencies cited during the health and safety check. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, May 3, 2024

Type of visit: Case Management - Incident

On 04/26/2024 at 3:00pm, Licensing Program Analyst (LPA) L. Alexander conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 04/03/2024. LPA met with Executive Director, Evelyn Jensen and explained the purpose of the visit. S1 stated that S2, the "Care Partner" for R1, reported to S3 that on 03/10/24 R1 said something that was sexual in nature to S2 after he asked R1 if they were ready for their shower. S1 stated that S3 went to R1 to speak with them but couldn't make out what R1 was saying. S1 stated that they called 911 and San Leandro PD was dispatch (Ref. 2024-12242). S1 stated that the police came to investigate the 911 call and when the police arrived to speak with R1 they also could not make out any understanding of what R1 was saying. S1 indicated that S2 was immediately taken off the care shower schedule for R1. S1 indicated that R1 is refusing care from the other Care Partners but R1 is not making any sexual natured statements neither. No deficiencies issued during the visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 26, 2024

Type of visit: Case Management - Incident

On 2/23/2024 at 2:40pm, Licensing Program Analyst (LPA) L. Hall conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 2/14/2024. LPA met with Sheila Rodriguez, Director of Sales and Mark Tabanera, Med Tech Manager, and explained the purpose of the visit. Incident report dated 2/13/2024, stated that a Resident 1 (R1) was given the wrong medication. The staff that administered the medication immediately notified the Medication Manager and was pulled from the schedule. Staff 2 (S2) also stated Staff 3 (S3) will complete medication management retraining. The incident report as well as S2 stated that all Med Techs completed an in-service training on six rights, three checks, and name alert protocol. LPA obtained a copy of the training documentation with signatures. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of the appeal rights and this report provided.the state’s words, verbatim · CDSS document, Feb 23, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(c)(2) · Plan of correction due date: Mar 4, 2024

87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. Based on record review the Licensee did not comply with the section cited above in administering medication to the correct resident, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 23, 2024

Plan of correction: Med Tech Manager agreed to submit copy of completed training for S3 to CCLD by POC date.

Allegation investigated: Sexual abuse

On 02/22/2024 at around 8:30 AM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct an unannounced complaint visit. LPA met with Community Executive Assistant, Daisy Monteon and explained the purpose of the visit. During the course of investigation, LPA conducted staff interview and records review. LPA conducted staff interview, based on interview, R1 have multiple episode (psychosis). Each time that R1 have develop an episode R1 states that R1 heating system is being hack along with R1 PG&E. LPA reviewed record of staff that was being allege as the abuser is not a staff at the facility nor have any information on the allege abuser anywhere on pay roll. Every time R1 have an episode S2 would preformed a check in R1 heating system to ensure R1 that there’s nothing in the heating system that R1 claimed. Facility replaced R1 heating system to reinsured R1 that there’s no devices/ nor anyone that is spying on R1. Report Continued on LIC 9099C... Unsubstantiated Based on interviews conducted and records review, the preponderance of evidence standard has not been met, therefore the allegation is found to be UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove it did or did not occur. Exit interview conducted and a copy of this report provided via email.the state’s words, verbatim · CDSS document, Feb 22, 2024 · control 15-AS-20240215160841

Type of visit: Required - 1 Year

On 10/13/23 at 11:00 a.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Executive Director, Nancy Randhawa and explained the purpose of the visit. The facility’s fire clearance was approved for 199. LPA toured the facility including but not limited to 3 residents’ apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 74 degrees F. The hot water temperature in a residents’ shared bathroom were measured at 107.3 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. LPA reviewed 5 residents records and 5 staff records and all were complete. LPA reviewed a sample of resident’s medications. 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

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.