Carlton Plaza of San Leandro.

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.

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 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 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. 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 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.

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.

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 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 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.

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.

...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.

...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.

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.

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.

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.

.... 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.

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.