Inspection Reports for Carlton Senior Living Davis
2726 5th St, Davis, CA 95618, United States, CA, 95618
Back to Facility ProfileInspection Report Summary
Most inspections at this facility were clean, with no deficiencies cited, including the most recent follow-up inspection on September 23, 2025, which found no issues. However, several complaint investigations substantiated concerns related primarily to resident supervision and staffing, including two incidents where residents with dementia eloped or fell due to inadequate supervision, resulting in serious injuries and civil penalties totaling $10,000. The facility also received citations for delayed outbreak reporting and failure to follow care plans, though other complaints about food service, hygiene, and odor control were unsubstantiated. Improvements were noted over time, with the May 15, 2025, plan of correction inspection clearing previous deficiencies and the latest report showing compliance. Several complaint investigations were unsubstantiated, indicating that many concerns raised did not result in findings against the facility.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
2.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
38% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
91% occupied
Based on a September 2025 inspection.
Census over time
Inspection Report
Follow-Up
Census: 136
Capacity: 150
Deficiencies: 0
Date: Sep 23, 2025
Visit Reason
The inspection was an unannounced case management follow-up visit to verify the Immediate Exclusion of Staff member S1 from the facility.
Findings
The Licensing Program Analyst verified that the excluded staff member S1 was no longer employed or present at the facility. No deficiencies were cited during the inspection.
Report Facts
Capacity: 150
Census: 136
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Blaine Lyons | Administrator | Met with Licensing Program Analyst during inspection |
| Jill Nakagawa | Licensing Program Analyst | Conducted the unannounced case management inspection |
| Kimberley Mota | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 136
Capacity: 150
Deficiencies: 2
Date: Jul 1, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by multiple allegations received on 2025-02-19 regarding staff response times to resident calls, adherence to care plans, resident repositioning, prevention of inappropriate behavior, and reporting requirements.
Complaint Details
The complaint investigation was substantiated for allegations that staff did not respond timely to call lights and did not follow care plans, including failure to use two-person assistance as required. The allegations regarding failure to reposition residents and prevent inappropriate behavior were unsubstantiated. The allegation regarding failure to follow reporting requirements was unfounded.
Findings
The investigation substantiated that staff did not respond to residents' call lights in a timely manner and did not follow residents' care plans, specifically regarding two-person assistance. The allegations that staff did not ensure resident repositioning and did not prevent inappropriate behavior were unsubstantiated. The allegation that staff did not follow reporting requirements was unfounded.
Deficiencies (2)
Facility personnel were not sufficient in numbers and competent to meet resident needs, evidenced by call light response times exceeding 60 minutes.
Staff ignored company policy of using two-person assist when care plan called for it and worked independently.
Report Facts
Call light calls: 310
Call light response times: 2
Census: 136
Total capacity: 150
Plan of Correction due date: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Nakagawa | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Kimberley Mota | Licensing Program Manager | Oversaw the complaint investigation |
| Blaine Lyons | Administrator | Facility administrator met with the Licensing Program Analyst during the investigation |
| Miriam Faris | Administrator | Named as facility administrator in the report header |
Inspection Report
Plan of Correction
Census: 139
Capacity: 150
Deficiencies: 0
Date: May 15, 2025
Visit Reason
Unannounced Plan of Correction (POC) inspection conducted to verify correction of previous deficiencies.
Findings
The facility was found to be clean and residents were appropriately cared for. Door alarms and delayed egress alarms were functioning properly. The Plan of Correction has been cleared with no deficiencies or citations issued at the time of inspection.
Report Facts
Residents in Memory Care unit: 32
Memory Care unit staff: 7
Activities personnel in Memory Care unit: 2
One-on-one staff: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mina Kutulas | Director of Resident Services | Met with Licensing Program Analyst during inspection and toured facility |
| Miriam Faris | Administrator | Administrator was out of the facility but available by phone during inspection |
| Jill Nakagawa | Licensing Program Analyst | Conducted the Plan of Correction inspection |
Inspection Report
Complaint Investigation
Census: 139
Capacity: 150
Deficiencies: 1
Date: May 6, 2025
Visit Reason
The visit was conducted as a Case Management - Incident Visit to follow up on a self-reported incident involving a resident elopement reported to Community Care Licensing.
Complaint Details
The visit was complaint-related, following a self-reported incident where Resident 1, diagnosed with dementia and unable to leave unassisted, eloped from the facility on 04/20/2025. The resident was found safe off premises 2.4 miles away. The complaint was substantiated with a deficiency cited and a civil penalty issued.
Findings
The facility failed to provide adequate supervision to a resident with dementia who eloped from the community, resulting in an immediate risk to the resident's health and safety. A civil penalty of $500 was issued for Zero Tolerance, Absence of Supervision.
Deficiencies (1)
Facility failed to provide supervision to Resident 1 resulting in an elopement, which is an immediate risk to health, safety, and rights of persons in care.
Report Facts
Civil Penalty Amount: 500
Resident Elopement Distance: 2.4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Miriam Faris | Administrator | Met with Licensing Program Analyst during inspection and involved in incident response |
| Jill Nakagawa | Licensing Program Analyst | Conducted the inspection visit |
| Kimberley Mota | Licensing Program Manager | Named as Licensing Program Manager overseeing the case |
Inspection Report
Complaint Investigation
Census: 139
Capacity: 150
Deficiencies: 1
Date: May 6, 2025
Visit Reason
An unannounced complaint investigation was conducted regarding allegations that staff were not taking precautions to mitigate the spread of illness in the facility.
Complaint Details
The complaint alleged that staff were not taking precautions to mitigate the spread of illness. The allegation was substantiated based on evidence that the Administrator did not notify the Department in the required timeframe.
Findings
The investigation found that the facility did not notify the Department within the required 24-hour timeframe about an outbreak of illness, substantiating the allegation. Several residents experienced vomiting and diarrhea, and the facility failed to report the outbreak timely as required by regulations.
Deficiencies (1)
Failure to report an outbreak within 24 hours as required by CCR 87211(a)(2).
Report Facts
Census: 139
Total Capacity: 150
Deficiencies cited: 1
Plan of Correction Due Date: May 12, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Nakagawa | Licensing Program Analyst | Conducted the complaint investigation |
| Kimberley Mota | Licensing Program Manager | Oversaw the complaint investigation |
| Miriam Faris | Administrator | Facility Administrator involved in findings and plan of correction |
Inspection Report
Annual Inspection
Census: 137
Capacity: 150
Deficiencies: 0
Date: Feb 4, 2025
Visit Reason
The inspection was an unannounced 1-Year Required Annual Inspection conducted to ensure the health and safety of residents in care.
Findings
The facility was observed to be clean, in good repair, and odor-free with necessary safety features in place. No immediate health, safety, or personal rights violations were observed, and all required documentation in resident and staff files was found.
Report Facts
Residents' files reviewed: 5
Staff files reviewed: 5
Perishable food storage duration: 2
Non-perishable food storage duration: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mina Kutulas | Director of Resident Services | Met with Licensing Program Analyst during inspection and involved in facility tour |
| Jill Nakagawa | Licensing Program Analyst | Conducted the inspection |
| Kimberley Mota | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 137
Capacity: 150
Deficiencies: 1
Date: Feb 4, 2025
Visit Reason
An unannounced Case Management visit was conducted to follow up on substantiated complaint allegations regarding neglect, lack of care and supervision resulting in severe injury and facility disrepair.
Complaint Details
Complaint number 21-AS-20230724142905 was substantiated for neglect and lack of care and supervision resulting in severe injury and facility disrepair.
Findings
The investigation substantiated neglect and lack of supervision leading to a resident (R1), identified as a fall risk, exiting the patio door unsupervised and falling outside, resulting in a fractured hip requiring hospitalization and surgery. A civil penalty of $9,500 was issued for serious bodily injury.
Deficiencies (1)
Violation of Health and Safety Code §1569.269(a)(6) Enumerated rights and CCR Title 22 §87303(a) Maintenance and Operation due to neglect and lack of supervision resulting in severe injury.
Report Facts
Civil penalty amount: 9500
Immediate civil penalty amount: 500
Resident census: 137
Facility capacity: 150
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Nakagawa | Licensing Program Analyst | Conducted the inspection and signed the report. |
| Miriam Faris | Administrator | Facility administrator met with Licensing Program Analyst during inspection. |
Inspection Report
Complaint Investigation
Census: 140
Capacity: 150
Deficiencies: 0
Date: Oct 19, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 07/22/2024 regarding inadequate toileting, food service, odor control, and addressing residents' condition changes.
Complaint Details
The complaint included allegations that staff did not ensure timely toileting, did not provide adequate food service, did not keep the facility free from odor, and did not address changes in residents' physical, medical, mental, and social conditions. All allegations were found to be unsubstantiated.
Findings
Based on observations, interviews, and records reviewed during visits on 07/24/2024 and 10/19/2024, there was no evidence to substantiate any of the allegations. Staff were found to provide adequate food service, maintain cleanliness and odor control, address changes in residents' conditions, and meet residents' toileting needs in a timely manner.
Report Facts
Capacity: 150
Census: 140
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Genai Bradshaw | Memory Care Activities Director (Acting Facilities Manager) | Met with during the investigation and named in relation to findings |
| Jill Nakagawa | Licensing Program Analyst | Conducted the complaint investigation |
| Kimberley Mota | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Census: 142
Capacity: 150
Deficiencies: 0
Date: May 30, 2024
Visit Reason
The visit was an informal meeting conducted to discuss an incident that occurred on February 17, 2023, which resulted in a complaint investigation with substantiated findings, and to address areas of concern including staffing and administrator duties.
Complaint Details
The visit was related to a complaint investigation with substantiated findings from an incident on February 17, 2023.
Findings
No deficiencies were cited during the informal conference office visit. The facility has implemented staffing improvements such as an evening supervisor and a 'hero position' to oversee operations and provide additional staff where needed.
Report Facts
Capacity: 150
Census: 142
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Miriam Faris | Administrator | Met during the visit and discussed staffing and administrative duties |
| Kimberley Mota | Licensing Program Manager | Present at the informal meeting |
| Jill Nakagawa | Licensing Program Analyst | Present at the informal meeting |
Inspection Report
Follow-Up
Census: 140
Capacity: 150
Deficiencies: 0
Date: Mar 8, 2024
Visit Reason
The visit was a Case Management - Incident inspection conducted to follow up on a self-reported incident involving residents R1 and R2.
Complaint Details
The visit was triggered by a self-reported incident report submitted to Community Care Licensing regarding residents R1 and R2. The Licensing Program Analyst reviewed incident details, gathered records, and took statements from the Administrator. Further follow-up will occur once additional information is gathered.
Findings
No deficiencies were found at the time of the visit and no citations were issued. The facility has been in contact with Police, Community Care Licensing, and the Ombudsman’s Office.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Miriam Faris | Administrator | Named in relation to statements taken during the incident follow-up visit. |
Inspection Report
Annual Inspection
Census: 140
Capacity: 150
Deficiencies: 0
Date: Jan 9, 2024
Visit Reason
An unannounced annual required 1-year inspection was conducted to evaluate compliance with regulations at Carlton Plaza of Davis.
Findings
The facility was found to be clean, well-maintained, and compliant with regulations. No deficiencies or citations were issued during the inspection.
Report Facts
Water temperature in bathrooms: 117
Inspection time: 3.07
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Miriam Faris | Administrator | Met with Licensing Program Analyst during inspection and exit interview. |
| Jill Nakagawa | Licensing Program Analyst | Conducted the unannounced annual inspection. |
Inspection Report
Complaint Investigation
Census: 140
Capacity: 150
Deficiencies: 1
Date: Jan 9, 2024
Visit Reason
Unannounced case management visit to investigate deficiencies related to failure to report an incident as required by regulation.
Complaint Details
Investigation revealed the facility did not report the incident as required. Staff attempted to send the report but received a 'failed to send' notification and did not resend, leading to the incident going unreported.
Findings
The facility failed to report an incident to the Community Care Licensing Regional Office due to a 'failed to send' notification that was not resent, resulting in the incident going unreported and posing a possible threat to resident health and safety.
Deficiencies (1)
Failure to submit a written report of a serious injury incident to the licensing agency within seven days as required by CCR Title 22, Division 6, Chapter 8.
Report Facts
Census: 140
Total Capacity: 150
Plan of Correction Due Date: Jan 10, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Miriam Faris | Administrator | Met with during inspection |
| Jill Nakagawa | Licensing Program Analyst | Conducted inspection and delivered findings |
| Kimberley Mota | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 140
Capacity: 150
Deficiencies: 2
Date: Jan 9, 2024
Visit Reason
Unannounced complaint investigation visit conducted due to allegations of neglect/lack of care and supervision resulting in severe injury and facility disrepair.
Complaint Details
Complaint was substantiated. The resident was left outside unsupervised for approximately one and a half hours, resulting in a hip fracture requiring surgery. Facility lighting issues were also substantiated as contributing factors.
Findings
Investigation substantiated neglect by staff resulting in a resident exiting the facility unsupervised, leading to a fall and hip fracture requiring hospitalization. Additionally, poor lighting in the patio area contributed to the fall and injury, confirming the facility was in disrepair.
Deficiencies (2)
Failure to provide care, supervision, and services that meet individual resident needs, resulting in resident injury.
Facility was not clean, safe, sanitary, and in good repair; lighting in patio area was unrepaired and contributed to resident fall and injury.
Report Facts
Civil penalty amount: 500
Capacity: 150
Census: 140
Inspection Report
Complaint Investigation
Census: 132
Capacity: 150
Deficiencies: 0
Date: Mar 10, 2023
Visit Reason
The visit was an unannounced case management inspection to follow up on a self-reported incident involving resident R1 and staff S1.
Complaint Details
The visit was triggered by a self-reported incident report submitted to Community Care Licensing regarding resident R1 and staff S1. The facility has been in contact with Police, CCL, and Ombudsman’s Office. The Licensing Program Analyst will review information and follow up once additional information is gathered.
Findings
The facility was found to be operating with COVID-19 protocols in place, including visitor screening and mask requirements. No deficiencies or citations were found at the time of the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Miriam Faris | Administrator | Administrator who provided statements during the incident follow-up visit. |
| Jill Nakagawa | Licensing Program Analyst | Conducted the case management inspection and gathered information. |
| Kimberley Mota | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Annual Inspection
Census: 139
Capacity: 150
Deficiencies: 0
Date: Jan 17, 2023
Visit Reason
An unannounced Annual Required – 1 year Infection Control inspection was conducted at Carlton Plaza of Davis.
Findings
The facility was found to be clean, with proper infection control measures in place, including mask-wearing by staff and proper food storage. No deficiencies or citations were issued during this inspection.
Report Facts
Facility Capacity: 150
Resident Census: 139
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Miriam Faris | Administrator | Met with Licensing Program Analyst during inspection |
| Jill Nakagawa | Licensing Program Analyst | Conducted the inspection |
| Kimberley Mota | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 135
Capacity: 150
Deficiencies: 0
Date: Sep 29, 2022
Visit Reason
Unannounced visit/investigation of a complaint received on 2022-09-02 alleging the facility did not notice a change of resident condition.
Complaint Details
The complaint alleged the facility did not notice a change in condition of resident (R1). The allegation was found unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation included a tour, record review, and interviews. Although the allegation may have happened or is valid, there was insufficient evidence to prove the violation occurred, resulting in an unsubstantiated finding with no deficiencies or citations issued.
Report Facts
Capacity: 150
Census: 135
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Miriam Faris | Administrator | Met with during investigation and named in report |
| Jill Nakagawa | Licensing Program Analyst | Conducted the complaint investigation |
| Kimberley Mota | Licensing Program Manager | Named in report |
Inspection Report
Census: 132
Capacity: 150
Deficiencies: 0
Date: Aug 26, 2022
Visit Reason
An unannounced inspection was conducted focusing on Covid-19 protocols following recent reported cases in the Memory Care Unit.
Findings
No deficiencies or citations were found during the inspection. The facility was clean, residents were well-groomed, and staff were observed following Covid-19 safety protocols including mask and glove use.
Report Facts
Census: 132
Total Capacity: 150
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Miriam Faris | Administrator | Met with Licensing Program Analyst and showed around the facility |
| Jill Nakagawa | Licensing Program Analyst | Conducted the unannounced inspection |
| Kimberley Mota | Licensing Program Manager | Named in report header |
Inspection Report
Capacity: 150
Deficiencies: 0
Date: Jun 23, 2022
Visit Reason
The inspection was an unannounced case management visit to check on the facility's hydration program for residents and review the Infection Control Plan.
Findings
No deficiencies or citations were found during the inspection. The facility has an Infection Control Plan being compiled, with six nurses designated as Infection Control Preventionists, and a hydration program in Memory Care with a variety of drinks offered to residents.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Genevieve Elder | Director of Resident Services | Met with Licensing Program Analyst during inspection and exit interview. |
| Miriam Faris | Administrator | Discussed facility operations and Infection Control Plan with Licensing Program Analyst. |
| Toni Jones | Memory Care Director | Discussed hydration program in Memory Care with Licensing Program Analyst. |
| Jill Nakagawa | Licensing Program Analyst | Conducted the unannounced inspection. |
Inspection Report
Complaint Investigation
Census: 137
Capacity: 150
Deficiencies: 0
Date: Apr 28, 2022
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation of questionable death and other complaints including neglect, lack of supervision, and failure to provide adequate care.
Complaint Details
The complaint investigation was initiated due to allegations including questionable death, neglect/lack of supervision resulting in pressure injuries and falls, failure to meet hygiene needs, failure to provide food service, and failure to ensure timely medical attention. The questionable death allegation was found unfounded, and other allegations were unsubstantiated.
Findings
The investigation found the allegation of questionable death to be unfounded with no citations issued. Other allegations related to neglect, hygiene, food service, falls, and medical attention were unsubstantiated due to insufficient evidence, and no citations were issued.
Report Facts
Capacity: 150
Census: 137
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Nakagawa | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Chris Arnhold | Licensing Program Analyst | Assisted in complaint investigation and delivery of findings |
| Miriam Faris | Administrator | Facility administrator met with investigators during the complaint investigation |
Inspection Report
Complaint Investigation
Census: 137
Capacity: 150
Deficiencies: 0
Date: Apr 28, 2022
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that residents were not being provided services and that the facility was not staffed adequately.
Complaint Details
The complaint was unsubstantiated due to lack of preponderance of evidence to prove the alleged violations occurred.
Findings
The investigation found that residents were being fed regularly, receiving bathroom and grooming assistance, and showering assistance was provided. Staffing records showed adequate staff to meet resident needs. The allegations were unsubstantiated and no citations were issued.
Report Facts
Capacity: 150
Census: 137
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Nakagawa | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Miriam Faris | Administrator | Met with investigators during the complaint investigation |
Inspection Report
Complaint Investigation
Census: 135
Capacity: 150
Deficiencies: 2
Date: Mar 23, 2022
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations including a resident not being provided bed linens and the facility not following proper COVID-19 protocols.
Complaint Details
The complaint was substantiated based on evidence including photographs, observations, interviews, and record reviews. The allegations of improper provision of bed linens and failure to follow COVID-19 PPE protocols were validated.
Findings
The investigation substantiated both allegations: the resident's bed was not made correctly lacking proper bottom sheets on multiple occasions, and staff failed to properly doff, discard, and store PPE during an active COVID-19 case, violating infection control requirements.
Deficiencies (2)
Failure to discard PPE in a tightly-lidded container as required, posing potential health, safety, and personal rights risks.
Failure to provide the resident with the required bottom bed sheet on multiple occasions, posing potential health, safety, and personal rights risks.
Report Facts
Capacity: 150
Census: 135
Deficiency count: 2
Plan of Correction Due Date: Mar 23, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Nakagawa | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Lindsey Feifert | Director of Resident Services | Met with the Licensing Program Analyst during the investigation |
Inspection Report
Annual Inspection
Census: 137
Capacity: 150
Deficiencies: 0
Date: Feb 10, 2022
Visit Reason
An unannounced Annual Required – 1 year Infection Control inspection was conducted at Carlton Plaza of Davis.
Findings
The facility was found to be clean, with proper infection control measures in place including PPE usage and Covid-19 protocols. No deficiencies or citations were issued during this inspection.
Report Facts
Facility Capacity: 150
Resident Census: 137
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Miriam Faris | Administrator | Met during inspection and exit interview |
| Jill Nakagawa | Licensing Program Analyst | Conducted the inspection |
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