Carlton Plaza of Fremont

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.

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.

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.

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.

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.

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.

On 7/15/2021 at 9:40AM, Licensing Program Analyst (LPA) L. Hall conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 7/8/2021. LPA met with Stephanie Brice, Executive Director (ED) and explained the purpose of the visit. Incident report dated 7/8/2021 revealed that S3 handled R1 roughly and abusively. Facility notified law enforcement and R1's responsible party. LPA interviewed two (2) staff, three (3) residents, obtained and reviewed documents provided which included physician's report, S3's statement, Fremont Police report number, appraisal needs and services, staff schedule and residents roster. During interviews S1 stated that S3 should have requested a 2nd caregiver to assist with R1. The three (3) residents stated that a couple of the staff handles them roughly but did not know the names of the staff. Based on LPAs' interviews and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D Exit interview conducted. Appeal rights and a copy of this report provided.

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.

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.

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.

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.

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.

On today’s date at 2:45 PM. Licensing Program Analyst (LPA) L. Fici and Licensing Program Manager (LPM) Y. Flores-Larios arrived unannounced to conduct a case management visit. LPA and LPM met Administrator (ADM), Meghian Geul and explained the purpose of the visit. LPA received an incident report dated of incident that occurred on 8/22/2022 regarding S1 using profanity towards R1 while assisting R1. Facility reported incident timely and completed all mandatory cross reporting as required. Facility S1 on administrative leave; pending investigation. LPA & LPM received a copy of the S1's statement regarding the incident. A review was conducted of S1 and R1's file. S1 has required training on file and is current. After facility conducted internal investigation, S1 was terminated on 8/26/2022 from the facility. S1 denies profanity was used towards R1 however facility had reviewed video footage from R1's sister which audio is clear on profanity being used. Facility conducted in-service training for all staff regarding resident's rights. No deficiencies are being cited on this date, Exit interview conducted with Administrator and a copy of report provided.

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.

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. 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 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... 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 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.

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.

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.

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.

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.

On 12/8/2022, at 11:19 AM, Licensing Program Analyst (LPA) Liridon Fici arrived unannounced to conduct an Annual Infection Control Visit. LPA was greeted by Administrator, Meghian Geul. During the inspection, LPA toured facility including but not limited to front entrance, kitchen, common areas, hand washing stations, bedrooms, bathrooms, and courtyard. LPA observed COVID-19 signage throughout the facility. Hand washing signs were posted at hand washing stations. LPA observed paper supplies and PPEs are sufficient. Facility has a sufficient 2-day perishable and 7-days non-perishable food supply. All sharps and toxins were locked up and inaccessible to residents in care. Common areas are disinfected frequently throughout the day. Water temperature is measured at 119.9 Degrees F. Fire extinguisher was last serviced on 2/25/2022. Facilities room temperature is maintained at 68 Degrees F. First aid kit is complete. Carbon monoxide and smoke detectors are functional. Facility passages inside and out are free of obstruction and does not pose a health and safety risk for persons in care. During record review, LPA observed facility has a copy of their Infection Control Plan and Disaster Plan on file. No deficiencies cited during visit. Exit interview conducted with Administrator and copy of this report provided.

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.

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.