Carlton Plaza of San Leandro

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.

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 9/20/2021 starting at 2:20pm, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to conduct an Infection Control Inspection. LPA met with Executive Director, Nancy Randhawa and explained the purpose of the visit. During the Infection Control Inspection, LPA toured facility including but not limited to front entrance, screening station, hand washing stations, apartment, common areas, kitchen and courtyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. Visitors policy is posted on the front entrance. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Facility has a mitigation plan and maintains record of routine screening for residents and staff. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

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 .

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.

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 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.

. . . 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.

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.

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 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.

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.

Resident was not allowed to manage their own medication. Interview with staff revealed that if a resident's medical assessment indicates that they cannot handle medications, then the resident would automatically be enrolled in the facility's medication program. LPA reviewed R1's medical assessment dated 3/16/2021 which states that R1 is not able to administer own prescription medication. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore these allegations are UNSUBSTANTIATED . No deficiencies are being cited on this date. Exit interview conducted. A copy of this report provided.

Staff did not notify responsible party of resident's change in condition Interview with staff revealed that managers or nurses would contact responsible party if resident has changes in condition and would be documented in the care notes. LPA observed care notes on 4/29/2022 states that R1 was coughing and not feeling well. Care notes on 4/29/2022 and 4/30/2022 did not indicate that responsible party was notified that R1 wasn't feeling well and coughing. Staff did not distribute resident's self administered medication as prescribed Care notes on 4/30/2022 at 5:28PM states that R1's family gave Med Tech some meds for R1 if needed. R1's April 2022 MAR indicates that Robitussin DM was entered at 4/30/2022 at 7:21PM and care notes revealed that R1 has a very strong cough since 4/30/2022 at 6:15AM. However, Robitussin was not administered to R1 until 5/1/2022. Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegations are 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 Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore these allegation is UNSUBSTANTIATED . No deficiencies are being cited on this date. Exit interview conducted. A copy of this report provided.

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.

Resident's phone is in disrepair LPA observed while at the facility on 3/30/23 that the facility has a working telephone for the resident’s use. This meets Title 22 regulation #80073. Facility falsified resident's diagnosis upon admission LPA G. Clark reviewed R1’s admission agreement dated 9/28/22, individual service plan dated 10/19/22 and physician’s report dated 9/23/22. LPA L. Hall interviewed S2 on 10/24/22. LPAs did not find any discrepancies among the reports and the staff interview regarding R1’s diagnosis. This agency has investigated the complaints alleging facility is not allowing resident to have visitors, resident's phone is in disrepair and facility falsified resident's diagnosis upon admission. We have found that the complaints were UNFOUNDED , meaning that the allegations were false, could not have happened and/or is without a reasonable basis. Exit interview conducted, a copy of this report provided.

During the course of investigation, LPA L. Fontanilla did the following: 1. On 3/23/22 interviewed Executive Director 2. On 3/25/22 interviewed Staff 2 (S2) 3. On 3/28/22 interviewed Staff 3 (S3) 4. On 3/22/22, reviewed video footage of incident, needs and services plan, admission agreement, Physician’s Report Based on interviews conducted with S2 and S3, they confirmed with LPA that they were working night shift on 6/19/2020. One is assigned to stay in the hallway to redirect residents and one stays with resident in the TV room. S2 is the assigned caregiver to stay with R1 in the TV room when the incident happened. S2 and S3 confirmed with LPA that R1 was already in the TV room when they started the shift. Both S2 and S3 state that R1 is ambulatory but they would always escort R1 in going to the restroom because R1 is unsteady. S2 confirmed with LPA that S2 was in the same room with R1 during the incident but did not notice R1 get up and walk. S2 states S2 was sitting facing the wall. When LPA asked S2 the reason for facing the wall, S2 states “I don’t know why I was facing the wall.” A review of R1’s Personal Service Plan Assessment dated 06-20-2020 indicates R1 needs transfer assistance requiring 1 caregiver if needed with: 1. Dressing/Undressing (AM and PM) 2. Bathing 3. Toileting The Service Plan also indicates staff will conduct periodic checks on R1 at bedtime when resident is sleeping in the room. And that R1 needs to be monitored for balance and safety. A review of the video footage from the incident shows R1 sleeping on the chair in the TV room. (Continue on LIC9099C...) 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 R1 woke up, looked around, pushed then pulled chair in front and tried to get up from the chair. R1 stood up and started walking but looked unsteady. R1 used chairs for support while walking towards the counter. When R1 was close to the counter, R1 lost balance, fell backwards with the chair on top of her. S2 came followed by S3. A review of R1’s medical records indicate R1 sustained closed displaced fracture of right femoral neck. R1 underwent right hip hemiarthroplasty. Based on interviews, video footage and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Sec. 1569.269(a)(10) and Sec. are being cited on the attached LIC 9099D. A $500.00 immediate civil penalty is assessed on this day. Civil penalty determination related to serious bodily injury is pending. Exit interview was conducted. A copy of this report, appeal rights, and civil penalty were provided to Executive Director, Nancy Randhawa . 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 Failure to provide appropriate sleeping arrangement. Failure to safeguard resident's personal belongings. On 3/25/22, LPA L. Fontanilla interviewed S2 and on 3/28/22, LPA interviewed S3. Staff interviewed confirmed with LPA that R1’s bed and personal belongings were in R1’s room when R1 was moved to the Memory Care Unit. Records reviewed indicate that on 6/19/2020, R1’s family was informed that all of R1’s belongings were moved to R1’s room in the Memory Care Unit. When interviewed by LPA on 3/25/2022, S2 states at the start of shift, R1 was already in the TV room sleeping. Staff from the previous shift told S2 that R1 refused to sleep in the room. S3 states they asked R1 to sleep in the room but R1 refused. Based on interviews conducted and records reviewed, the above allegations are unsubstantiated. 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. There is no deficiency noted. Exit interview was conducted and a copy of this report was provided to Executive Director, Nancy Randhawa .

Continued from LIC9099. which states “The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis…” Therefore, the facility had the right to coerce R1 into seeking medical attention. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided.

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.