CARLTON PLAZA OF SAN LEANDRO

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

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.

Official 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

Deadline recorded: Apr 30, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)(8)

Regulation authority

CCR

What the official deficiency says

(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.

Official 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.

Deadline recorded: May 5, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87413(a)(2)

Regulation authority

CCR

What the official deficiency says

(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.

Official 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.

Deadline recorded: May 5, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87625(b)(3)

Regulation authority

CCR

What the official deficiency says

(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.

Official 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.

Deadline recorded: May 5, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(f)

Regulation authority

CCR

What the official deficiency says

(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.

Official 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.

Deadline recorded: May 5, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

(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.

Official plan of correction

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

Deadline recorded: Dec 11, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

(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.

Official 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.

Deadline recorded: Dec 11, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(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 which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in having a filled gasoline tank in an unlocked shed outside assessible to residents which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/04/2025 Plan of Correction Maintenance staff immediately locked the shed. Deficiency cleared during visit.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above in that the call button was not signaling on the second floor common restroom and having damaged floors in residents room which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 09/10/2025 Plan of Correction Administrator agrees to test all call buttons to ensure they are in working conditions and contact CCLD by POC date. Administrator agrees to make repairs to damaged floors, review regulation and notify CCLD by POC date.

Official classification

Type B

Official code

87412(f)

Regulation authority

CCR

What the official deficiency says

(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements: This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in that the personnel records were not readily available upon demand and were incomplete which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 09/10/2025 Plan of Correction Administrator agrees to review all staff records and develop a plan to ensure staff records are available and review regulation and notify CCLD by POC date.

Official classification

Type B

Official code

87555(a)

Regulation authority

CCR

What the official deficiency says

(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents an shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in that the facility not ensuring proper food storage which poses a potential health risk to persons in care.

Official plan of correction

POC Due Date: 09/10/2025 Plan of Correction Administrator agrees to ensure food containers are properly stored, review regulation and notify CCLD by POC date.

Official classification

Type B

Official code

87463(b)

Regulation authority

CCR

What the official deficiency says

(b) The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented as specified in Section 87466, Observation of the Resident. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in that the facility did not update R6's appraisal needs and services plan based on a change of condition which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 09/10/2025 Plan of Correction Administrator agrees to review all residents appraisal needs and services plan and update them as necessary and notify CCLD by POC date.

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1)Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in that three (3) staff members had expired first aid certificates which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 09/10/2025 Plan of Correction Administrator agrees to ensure all required staff have updated first aid certifications and notify CCLD by POC date.

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in that resident records were not readily avaiable upon demand and were observed to be incomplete which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 09/10/2025 Plan of Correction Administrator agrees to review all resident records and develop a plan to ensure resident records are available and review regulation and notify CCLD by POC date.

Official classification

Type B

Official code

87555(b)(9)

Regulation authority

CCR

What the official deficiency says

(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.

Official 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.

Deadline recorded: Dec 30, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87466

Regulation authority

CCR

What the official deficiency says

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.

Official 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

Deadline recorded: Dec 30, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87202(a)(1)

Regulation authority

CCR

What the official deficiency says

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.

Official 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.

Deadline recorded: Dec 4, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(b)(27)

Regulation authority

CCR

What the official deficiency says

(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.

Official plan of correction

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

Deadline recorded: Dec 11, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)(1)

Regulation authority

CCR

What the official deficiency says

(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.

Official plan of correction

By POC date Facility agrees to sanitize and clean kitchen and notify CCLD.

Deadline recorded: Dec 11, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87204(a)

Regulation authority

CCR

What the official deficiency says

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.

Official 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.

Deadline recorded: Oct 14, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(e)

Regulation authority

CCR

What the official deficiency says

(e) Swimming pools and other bodies of water shall be fenced and in compliance with state and local building codes. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in two (2) of two (2) fountains which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/23/2024 Plan of Correction To fill bodies of water with rock and send a picture to LPA

Official classification

Type B

Official code

87202(a)(1)

Regulation authority

CCR

What the official deficiency says

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.

Official 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.

Deadline recorded: May 30, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

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

Deadline recorded: Mar 4, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87405(d)(2)

Regulation authority

CCR

What the official deficiency says

Administrator - Qualifications and Duties. Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement is not met as evidence by: Based on investigation, licensee did not comply with the section cited above by not testing resident with symptoms which poses a potential health and safety risk to the persons in care.

Official plan of correction

Facility has agreed to submit a written plan regarding reviewing CCLD PINs and submit the written plan to CCLD by POC date.

Deadline recorded: May 15, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care. Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidence by: Based on investigation, licensee did not comply with the section cited above by not administering PRN medication which poses an immediate health and safety risk to the persons in care.

Official plan of correction

Facility has agreed to conduct training for staff that administer medications and submit staff sign-in sheet and training materials to CCLD by POC date.

Deadline recorded: May 8, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87405(d)(2)

Regulation authority

CCR

What the official deficiency says

Administrator - Qualifications and Duties. Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement is not met as evidence by: Based on investigation, licensee did not comply with the section cited above by not testing resident with symptoms which poses a potential health and safety risk to the persons in care.

Official plan of correction

Facility has agreed to submit a written plan regarding reviewing CCLD PINs and submit the written plan to CCLD by POC date.

Deadline recorded: May 15, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(8)

Regulation authority

CCR

What the official deficiency says

Personal Rights of Residents in All Facilities. To have their representatives regularly informed by the licensee of activities related to care or services... This requirement is not met as evidence by: Based on investigation, licensee did not comply with the section cited above by not notifying R1's family when R1 had a change in condition which poses a potential health and safety risk to the persons in care.

Official plan of correction

Facility has agreed to conduct training on notifying resident's representatives and submit staff sign-in sheet and materials to CCLD by POC date.

Deadline recorded: May 15, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.269(a)(10)

Regulation authority

HSC

What the official deficiency says

Enumerated rights; severability. To be free from neglect,..., intimidation, and verbal, mental, physical, or sexual abuse. This This requirement is not met as evidenced by: Based on interviews conducted, records and video footage reviewed, on 6/20/2020 facility staff failed to assist R1 when R1 woke up, got up from the chair and walked which resulted to R1 falling and sustained fracture of right femoral neck. R1 underwent right hip hemiarthroplasty and has moved out of the facility.

Official plan of correction

By POC date, Executive Director will conduct training with all staff of Sec. 1569.269 Enumerated Rights and submit proof of training and sign in sheet to CCL. A Non-Compliance Conference (NCC) will be scheduled. A $500.00 immediate civil penalty is assessed on this day. Civil penalty determination related to serious bodily injury is pending.

Deadline recorded: Jun 24, 2022. A deadline is not proof that correction was completed.