Carlton Plaza of Davis.

Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to continue a case management and gather information/records regarding incidents on 4/19/2026 self reported by the facility on 4/20/2026 that involved staff S1, S2, S3 and residents R1 and R2. LPA met with Executive Director Blaine Lyons and collected video files. Exit interview conducted and copy of report left with Executive Director.

Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to continue a case management regarding an incident that occurred on 04/19/2026. LPA met with Executive Director Blaine Lyons. LPA requested the following information/records for Community Care Licensing regarding incidents on 4/19/2026 self reported by the facility on 4/20/2026. * LIC500 * Video of Incident * Termination Forms * LIC855 - Declaration Forms Exit interview conducted and copy of report left with Executive Director.

Licensing Program Analyst (LPA), Jill Nakagawa, arrived at facility unannounced to conduct a case management visit regarding a self reported incident report and SOC341 dated 02/23/2026. LPA met with the Administrator, Blaine Lyons and Mina Kutulas, Director of Resident Services. Administrator made a police report (Case #26-738), contacted responsible party of R1, conducted an internal investigation, reached out to R1's health team. LPA toured the facility, made observations, reviewed records and conducted interviews. No deficiencies cited during this inspection.

On 01/22/2026, Licensing Program Analyst (LPA) Jill Nakagawa, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Blaine Lyons, Administrator and explained the purpose of the visit. LPA Nakagawa and Mina Kutulas, Director of Resident Services toured facility together to ensure health and safety of residents in care. Areas toured included but are not limited to: common areas, resident bedrooms of Memory Care unit, common restrooms, kitchen, dining room, activities rooms and several resident apartments. LPA observed the facility to be clean, in good repair and odor-free. Each bathroom inspected was equipped with the necessary grab bars, non-skid flooring or shower chair, paper towels and hand soap. Water temperature measured approximately 113 degrees F throughout the facility, which is within regulation. LPA observed each bedroom to have the necessary furnishings with working lights and windows with screens. LPA observed organized activities held throughout the day in Memory Care and outings planned for Assisted Living. The dining area was clean and sanitary and the layout made it easy for residents with walkers and wheelchairs to access the tables and move about to socialize. The newly renovated Great Room had an operating fireplace with screen, and comfy chairs set up for easily accessed social spaces. Facility has a 2-day perishable and a 7-day non-perishable amount of food and sharps to be locked. LPA observed several fire extinguishers which were fully charged and last serviced on 1/11/2026. Fire inspection of fire/smoke detectors as well as fire drill for all shifts was held on 1/11/2026. In the areas toured no immediate health, safety, or personal rights violations were observed. Continued on 809-C.... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Continued from 809... LPA reviewed a total of five (5) residents' files and five (5) staff files which contained all the required documentation. Resident files were on-line but are accessible by staff at any time. LPA was able to find all required documentation. Several topics were discussed including the interactive Memory Care activities program. No deficiencies are being cited as a result of today’s inspection.

LIcensing Program Analyst (LPA) Jill Nakagawa conducted an unannounced case management and met with Administrator Blaine Lyons. The purpose of this case management inspection is to follow up on an Immediate Exclusion from the facility for Staff (S1). LPA provided a copy of the letter "Order to Licensee/Facility of Immediate Exclusion from Facility" dated September 19, 2025 for S1. Documentation shows S1 was employed briefly; last day of employment was 02/21/2023 and is no longer employed by Carlton Plaza of Davis and is not present in the building. Based on evidence obtained during today's visit, the LPA has verified the individual is not present, working at or residing at the facility #577005341. A check of the Guardian Roster verified that S1 was not listed as an employee. No deficiencies cited during today's inspection. Copy of letter provided to Blaine Lyons, Administrator.

On 05/15/2025, Licensing Program Analyst (LPA) Jill Nakagawa, arrived at the facility unannounced to conduct a Plan of Correction (POC) inspection. LPA met with Director of Resident Services, Mina Kutulas and explained the purpose of the visit. Administrator Miriam Faris was out of the facility but available by phone. LPA Nakagawa and Mina Kutulas toured facility together to ensure health and safety of residents in care. The Memory Care unit was staffed with 2 activities personnel, one staff as a one-on-one for a resident in care, 32 residents and 7 staff plus the Director of Memory Care. The unit was clean, the residents were clean and dressed appropriately, with many of them participating in activities in the main living room. LPA and Mina Kutulas inspected the patio area. Door alarms were working and loud enough to be heard. The outside gate which has a delayed egress was also checked. A new audible alarm was added which rings loudly and distinctly in the living room any time the delayed egress is opened, which will alert staff throughout the unit. POC has been cleared. No deficiencies found at the time of inspection. No citations issued.

On 02/04/2025, Licensing Program Analyst (LPA) Jill Nakagawa, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Resident Care Director Mina Kutulas and explained the purpose of the visit. LPA Nakagawa and Mina Kutulas toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms of Memory Care unit, common restrooms, kitchen, dining room, actvities rooms and several resident apartments. LPA observed the facility to be clean, in good repair and odor-free. Each bathroom to have the necessary grab bars, non-skid flooring or shower chair, paper towels, trash can with lids. LPA observed each bedroom to have the necessary furnishings with working lights and windows with screens. LPA received multiple compliments from AL residents regarding care and food. Facility has a 2-day perishable and a 7-day non-perishable amount of food and sharps to be locked. LPA observed several fire extinguishers, fire/smoke detectors. LPA observed the first aid kit to be complete and ready for use. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA reviewed a total of five (5) residents' files and five (5) staff files which contained all the required documentation. Resident files were on-line but are accessible by staff at any time. LPA was able to find all required documentation. Several topics were discussed. No deficiencies are being cited as a result of today’s inspection. Exit interview conducted and copy of report left at the facility.

Licensing Program Analyst (LPA) Jill Nakagawa arrived on February 4, 2025 for an unannounced Case Management visit to follow up on substantiated complaint allegations: complaint number 21-AS-20230724142905. LPA met with Miriam Faris, Administrator and explained the purpose of the visit. On January 9, 2024, the Department concluded an investigation which alleged that Neglect/Lack of Care and Supervision resulting in severe injury and Facility in disrepair. The allegations were substantiated, and the licensee was cited for violating Health and Safety Code (H&S) §1569.269(a)(6) Enumerated rights; and California Code of Regulations (CCR) Title 22 §87303(a) Maintenance and Operation. At the time of the complaint visit on January 9, 2024, an immediate civil penalty for Health and Safety Code §1569.269(a)(b) of $500 was issued. The licensee was informed that an additional civil penalty was being determined and might be assessed based on Health and Safety Code §1569.49. The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code §15610.67 defines serious bodily injury as "an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by the facilities lack of supervision on February 17, 2023, when a resident (R1) who was identified as a fall risk and required additional supervision, was able to exit the patio door, go outside unsupervised and fall. Continued on 809-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Continued from 809.... Staff (S1) last observed R1 at approximately 1800 hours sitting in a wheelchair near the patio door. Staff (S2) reported that on February 17, 2023, at approximately 1800 hours, surveillance video showed R1 exit the patio door and go outside unsupervised. Staff (S3), who was covering for S4 who was on break, was observed on camera in the living room area close to the patio door and did not turn around or respond to the patio door alarms. While outside unattended on the unlit patio for approximately one and a half hours, R1 fell and sustained a fractured hip resulting in hospitalization and surgery. Today February 4, 2025, the Department is issuing a civil penalty per Health and Safety Code §1569.49 for a violation that the Department constitutes as serious bodily injury resulting in the hospitalization of a resident, in the amount of $10,000. However, since an immediate civil penalty of $500 was previously issued on January 9, 2024, the amount of the civil penalty issued today will be $9,500. Exit interview conducted. A copy of the report has been issued. Appeal rights provided. Facility representative and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.

Continued from 9099.... Based on LPA’s observations, interviews, and records reviewed, there is no evidence to support the allegation that staff are not providing residents with adequate food service. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated . Staff did not address changes to resident's physical, medical, mental, and social condition. LPA made observations, conducted interviews, and reviewed records and found that staff monitor all residents for changes in condition. LPA reviewed physician reports and care plans. The care team is aware of residents’ needs and continuously monitor for changes in condition and did not find any evidence of changes not being addressed. 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 that staff did not address changes to resident’s physical, medical, mental, and social condition is unsubstantiated. Staff do not keep the facility free from odor: LPA conducted facility visits on 7/24/2024 and 10/19/2024 and found resident rooms in memory care to be clean and odor-free. LPA inspected rooms in the Assisted Living section on the same dates and found no concerns for cleanliness or observed any odors. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation that Staff do not keep the facility free from odor is unsubstantiated. Staff do not ensure residents toileting needs are met in a timely manner: LPA made observations and reviewed records. LPA conducted facility visits on 07/24/2024 and 10/19/2024 and found that residents appeared clean and dressed appropriately. A review of records found that hygiene and toileting needs are logged regularly by staff which show that toileting is conducted approximately every two hours. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation that Staff do not ensure residents toileting needs are met in a timely manner is unsubstantiated.

An informal meeting was conducted today in the Santa Rosa Regional Office. Present in the meeting were Licensing Program Manager, Kimberley Mota, Licensing Program Analyst, Jill Nakagawa, Administrator, Miriam Faris, Vice President of Corporate Development, Lindsay Flores and, VP Clinical Operations, Marco Santos. The purpose of the informal meeting was to discuss an incident that occurred at the facility on February 17, 2023 that resulted in a complaint investigation with substantiated findings. In addition, the following areas of concern were discussed: * Adequate staffing in the memory care unit: training of staff to include understanding the importance of staggered breaks. In addition, Administrator to monitor the care needs of residents and proper staffing levels to meet these needs. *Administrator's Duties: Administrator to ensure adherence to reporting requirements, ensuring safety of buildings and grounds. Administrator has implemented: Evening supervisor (2:30 PM to 10:45 PM) whose primary duty is not to provide care giving (although they are trained if needed), but to oversee evening operations. In addition Administrator states that facility has implemented a "hero position" which is an additional staff member where needed. Continued on LIC809-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Documents requested during informal meeting to be submitted to CCL by May 31,2024.: · Licensee will submit an updated LIC500 indicating staff coverage in all areas of the facility.. No deficiencies cited during today’s informal conference office visit.

Licensing Program Analysts (LPAs) Stefanie Mutialu and Jill Nakagawa arrived unannounced at Carlton Plaza of Davis to conduct a Case Management - Inspection. The purpose of this case management visit was to follow up on self reported incident report that was submitted to Community Care Licensing (CCL) regarding residents R1 and R2. During visit LPA went over incident details, gathered records, took statements from Administrator. Facility has been in contact with Police, CCL and Ombudsmans' Office. LPA will review information and will follow up with facility, once additional information is gathered and reviewed. No deficiencies were found at the time of visit. No citations issued.

Licensing Program Analyst (LPA) Jill Nakagawa conducted an unannounced Annual Required – 1 yr. at Carlton Plaza of Davis on 01/09/24 at approximately 02:05 PM and met with Administrator Miriam Faris. There were 140 residents present. During facility tour with Administrator, facility was found to be clean and at a comfortable temperature of 74 F with all exits free from obstruction. At the time of inspection there was an activity in Memory Care with a large group of participants. Several residents' apartments, common areas, kitchen & food storage areas, Memory Care Unit, and outside sitting areas were inspected. Fire Extinguishers and Fire Protection System were inspected by Cosco Fire Protection on 11/27/23. All fire extinguishers in the facility were charged and tested on 11/27/23. Inspection of the kitchen showed there was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator and freezer were properly stored as per regulations on this day at the time of the visit. Toxins and dangerous items are stored in laundry room behind locked doors; providing inaccessibility to residents. There is also a chemical room off of the kitchen with a supply of cleaners, hygiene products and paper products available for clients which is locked and inaccessible to residents. Facility has an Infection Control Plan. All bathrooms were provided with hand soap and paper towels. Water temperature in bathrooms inspected measured 117 - 117.4 F. There were no deficiencies or citations issued during this inspection. Exit interview conducted with Administrator, Miriam Faris.