Inspection Reports for
Carlton Plaza of San Leandro

The complaint investigation was substantiated for allegations that the facility boiler was in disrepair causing lack of hot water and that staff did not ensure resident needs were met. The allegation that staff did not ensure all residents had means to call for assistance was unsubstantiated.

The investigation substantiated that the facility's boiler malfunctioned and left the building without hot water for two days, and staff were not making rounds every two hours, only responding when residents used call buttons or Alexa. Another allegation that staff did not ensure all residents had means to call for assistance was unsubstantiated.

The inspection identified multiple deficiencies including an unlocked shed with a filled gasoline tank, incomplete personnel and resident records, expired first aid certifications for staff, improperly stored food containers, malfunctioning call buttons, damaged floors, and outdated resident appraisal and service plans.

The complaint investigation was substantiated for the allegation that staff did not seek timely medical attention for a resident. The allegation that staff neglect resulted in a resident's death was found to be unfounded.

The allegation regarding failure to seek timely medical attention was substantiated, with evidence showing delayed medical response after a medication error. The allegation of staff neglect resulting in a resident's death was found to be unfounded based on medical records and death certificate review.

The facility was found to have improperly stored food in the kitchen refrigerators, including open raw chicken and uncovered peaches, posing a potential health and safety risk. Previous deficiencies related to insects and dirty kitchen surfaces were cleared.

The complaint was substantiated. The allegation that the third floor had too many non-ambulatory residents was confirmed by review of resident rosters and ambulation reports.

The investigation substantiated the allegation that the third floor had 8 non-ambulatory residents, exceeding the approved capacity of 6. An immediate civil penalty of $250 was assessed for this repeat violation.

The visit was triggered by a priority 1 complaint. The complaint was substantiated by observations of unsanitary conditions in the kitchen area.

The inspection found small black flying bugs in the kitchen/food area and dirty, sticky kitchen floors. These conditions pose potential health and personal rights risks to residents.

The facility was cited for not complying with the limitation on the number of non-ambulatory residents on the third floor, where 12 residents were observed instead of the allowed 6, posing a potential health, safety, or personal rights risk.

The facility was generally compliant with safety and operational standards, but a Type B citation was issued for noncompliance related to unfenced bodies of water posing a safety risk.

The complaint alleging too many non-ambulatory residents on the third floor was substantiated based on evidence that the number of nonambulatory residents exceeded the licensed fire clearance capacity.

The complaint was substantiated. The facility has 19 nonambulatory residents on the third floor, exceeding the licensed fire clearance capacity of 6, posing a potential health, safety, or personal rights risk. A $500 immediate civil penalty was assessed.

The visit was triggered by a complaint regarding a medication error involving Resident 1. The complaint was substantiated based on record review.

The Licensee failed to comply with medication administration requirements, resulting in a resident receiving the wrong medication. Staff involved received retraining and in-service training on medication protocols was documented.

The complaint investigation was substantiated for failure to follow COVID-19 protocol, failure to notify responsible party of resident's change in condition, and failure to distribute medication as prescribed. One allegation regarding failure to assist resident with obtaining medical care was unsubstantiated.

The investigation substantiated that the facility did not follow COVID-19 protocol, failed to notify the responsible party of a resident's change in condition, and did not administer prescribed medication timely. One allegation regarding failure to assist a resident with obtaining medical care was unsubstantiated.

The complaint was substantiated. The investigation found that the facility failed to test a symptomatic resident for COVID-19 promptly, which posed a potential health and safety risk to persons in care.

The allegation was substantiated based on investigation findings that the facility did not test a resident with symptoms for COVID-19 in a timely manner, posing a potential health and safety risk.

The complaint investigation was substantiated for failure to provide adequate supervision resulting in a fracture. Other allegations including overcharging for services, failure to safeguard personal belongings, and failure to provide appropriate sleeping arrangements were unsubstantiated.

The allegation of failure to provide adequate supervision resulting in a fracture was substantiated based on interviews, video footage, and records. The resident sustained a right femoral neck fracture requiring surgery. Other allegations regarding overcharging, safeguarding belongings, and sleeping arrangements were unsubstantiated due to lack of evidence.