Inspection Reports for Carlton Senior Living Pleasant Hill – Martinez
2770 Pleasant Hill Rd, Pleasant Hill, CA 94523, United States, CA, 94523
Back to Facility ProfileInspection Report Summary
Most inspections found deficiencies, primarily related to resident rights and safety issues such as improper eviction notices, unlocked medications, and fire hazards. Several complaint investigations were substantiated, including failures in eviction procedures, reappraisal of residents’ conditions, and timely reporting of hospitalizations to the licensing authority. The most recent report from October 8, 2025, cited two deficiencies involving unlocked medication posing an immediate safety risk and missing health screening documentation for staff. While some investigations found no problems and a few earlier annual inspections were clean, the facility’s record shows ongoing challenges with compliance in documentation and resident care procedures. There is no indication of fines or license actions in the available reports.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 139
Capacity: 165
Deficiencies: 2
Oct 8, 2025
Visit Reason
The inspection was an unannounced required annual inspection conducted to evaluate compliance with licensing requirements at the facility.
Findings
The inspection found two deficiencies: unlocked medication in a resident's bathroom posing an immediate health and safety risk, and missing health screening and TB clearance documentation for two staff members. Plans of correction were requested with due dates.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Unlocked medication left in bathroom sink counter posing immediate health, safety, or personal rights risk to persons in care. | Type A |
| Staff members S1 and S2 did not have health screening and TB clearance on file, posing a potential health, safety, or personal rights risk to persons in care. | Type B |
Report Facts
Residents' rooms toured: 8
Residents' records reviewed: 8
Staff records reviewed: 9
Hot water temperature readings: 109.6
Hot water temperature readings: 104.6
Hot water temperature readings: 105.1
Hot water temperature readings: 110
Fire extinguisher last inspected: Jul 23, 2025
Emergency disaster plan last updated: Sep 10, 2025
Fire drill last conducted: Aug 27, 2025
Liability insurance effective period start: Jul 1, 2025
Liability insurance effective period end: Jul 1, 2026
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jon McCraw | Executive Director | Administrator named in relation to medication storage deficiency and facility tour |
| Lori Alexander-Washington | Licensing Program Analyst | Conducted inspection and signed report |
| Bennett Fong | Licensing Program Manager | Named as Licensing Program Manager overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 140
Capacity: 165
Deficiencies: 1
Jul 31, 2025
Visit Reason
The visit was an unannounced case management visit conducted on 07/31/2025, triggered by a complaint investigation (#15-AS-20241025150045) regarding eviction procedures.
Findings
A deficiency was observed where an eviction letter dated 10/14/2024 issued to a resident did not comply with the California Code of Regulations, Title 22, under Eviction Procedures. This posed a potential health and safety risk to persons in care.
Complaint Details
The complaint investigation (#15-AS-20241025150045) found that the eviction notice did not meet regulatory requirements, posing a potential health and safety risk. The deficiency was cited and a plan of correction due by 08/08/2025 was established.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Eviction letter dated 10/14/2024 issued to R1 did not ensure eviction notice is in compliance with regulation under Eviction Procedures. | Type B |
Report Facts
Census: 140
Total Capacity: 165
Plan of Correction Due Date: Aug 8, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| John McCraw | Executive Director | Met with Licensing Program Analyst during inspection |
| Grace Luk | Licensing Program Analyst | Conducted the case management visit and signed the report |
| L. Alexander-Washington | Conducted the complaint investigation | |
| Harpreet Humpal | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 143
Capacity: 165
Deficiencies: 0
Jul 17, 2025
Visit Reason
The visit was an unannounced case management follow-up on a death report received by Community Care Licensing regarding a resident who passed away on 07/14/2025.
Findings
No deficiencies were issued during the visit. Licensing Program Analysts obtained additional information related to the resident's death, including a physician's report and pending death certificate.
Report Facts
Capacity: 165
Census: 143
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jon McCraw | Executive Director | Met with Licensing Program Analysts during the visit |
| Lori Alexander-Washington | Licensing Program Analyst | Conducted the inspection visit |
| Bennett Fong | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 143
Capacity: 165
Deficiencies: 1
Jun 19, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-04-18 alleging that the facility did not provide a safe environment for residents in care.
Findings
The investigation found substantiated deficiencies related to fire safety, specifically trash and recycle bins in the stairwells posing an immediate fire hazard and obstruction in the path of egress. The facility doors had gaps that were not fixed as scheduled due to circumstances beyond the facility's control. The trash and recycle bins were removed as required.
Complaint Details
The complaint was substantiated. The allegation was that the facility did not provide a safe environment for residents in care due to fire safety issues including gaps on doors and trash in stairwells. The fire marshal identified the trash as an immediate risk.
Deficiencies (1)
| Description |
|---|
| Trash and recycle bins in the stairwells posed an immediate safety risk and fire hazard, obstructing the path of egress. |
Report Facts
Capacity: 165
Census: 143
Deficiency Type: 1
Plan of Correction Due Date: Jun 20, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jon McCraw | Executive Director | Met with Licensing Program Analyst during investigation and discussed findings |
| Alicia Delmundo | Licensing Program Analyst | Conducted the complaint investigation visit |
| Bennett Fong | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Capacity: 165
Deficiencies: 0
Apr 10, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation that staff unlawfully evicted a resident.
Findings
The investigation found the allegation to be unfounded. The eviction notice met procedural requirements, and the facility continues to provide care to the resident despite refusal of help with activities of daily living. No deficiencies were cited during the visit.
Complaint Details
The complaint alleged that staff unlawfully evicted a resident. The allegation was found to be unfounded, meaning it was false, could not have happened, or was without reasonable basis.
Report Facts
Facility capacity: 165
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jon McCraw | Executive Director | Met with Licensing Program Analyst during investigation and mentioned in findings |
| Lori Alexander-Washington | Licensing Program Analyst | Conducted the complaint investigation visit |
| Bennett Fong | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 149
Capacity: 165
Deficiencies: 1
Apr 10, 2025
Visit Reason
The visit was an unannounced Case Management inspection conducted concurrently with a complaint investigation regarding a resident's behavior and care.
Findings
The investigation found that the facility failed to perform updated appraisals and medical assessments to address new behaviors of a resident who made sexual advances towards staff. A deficiency was cited for not complying with reappraisal requirements after significant changes in condition.
Complaint Details
The complaint investigation (15-AS-20241025150045) involved review of records for Resident (R1) who exhibited new behaviors including sexual advances towards staff. The facility did not update appraisals or medical assessments timely to address these behaviors.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to perform reappraisals in significant changes of condition and bring such changes to the attention of appropriate licensed medical professionals. | Type B |
Report Facts
Census: 149
Total Capacity: 165
Deficiency Type B: 1
Plan of Correction Due Date: Apr 17, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jon McCraw | Executive Director | Met with Licensing Program Analyst during inspection |
| Lori Alexander-Washington | Licensing Program Analyst | Conducted the inspection and complaint investigation |
| Bennett Fong | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 143
Capacity: 165
Deficiencies: 0
Feb 11, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation that staff were not accepting a resident back for re-entry.
Findings
The investigation found the complaint to be unfounded, meaning the allegation was false or without reasonable basis. No deficiencies were cited during the visit.
Complaint Details
The complaint alleged that staff were not accepting resident R1 back for re-entry. The investigation included interviews and review of documentation, including an exception request and physician's report. The Department granted approval for the resident's re-entry, and the complaint was determined to be unfounded.
Report Facts
Capacity: 165
Census: 143
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jon McCraw | Executive Director | Met with Licensing Program Analyst during the investigation |
| Lori Alexander-Washington | Licensing Program Analyst | Conducted the complaint investigation |
| Bennett Fong | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 143
Capacity: 165
Deficiencies: 1
Feb 11, 2025
Visit Reason
The visit was an unannounced Case Management visit conducted to investigate a complaint regarding the facility's failure to notify the Community Care Licensing Division (CCLD) of a resident's hospitalization.
Findings
The facility was found to have deficiencies related to failure to notify CCLD of a resident's hospitalization, which poses a potential health, safety, and personal rights risk to persons in care. An incident report was generated but lacked confirmation of receipt by CCLD.
Complaint Details
The complaint investigation (15-AS-20250205123313) found the facility did not notify CCLD of Resident 1's hospitalization. Staff interviews and record reviews confirmed the deficiency. The complaint is substantiated by the cited deficiency.
Deficiencies (1)
| Description |
|---|
| Failure to comply with reporting requirements by not notifying CCLD of Resident 1's hospitalization as required by California Code of Regulation, Title 22, Section 87211. |
Report Facts
Capacity: 165
Census: 143
Plan of Correction Due Date: Due date for Plan of Correction is 02/18/2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jon McCraw | Executive Director | Met with Licensing Program Analyst during inspection and mentioned in findings |
| Lori Alexander-Washington | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Bennett Fong | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 149
Capacity: 165
Deficiencies: 1
Nov 26, 2024
Visit Reason
The inspection visit was an unannounced complaint investigation conducted in response to an allegation of illegal eviction received on 2024-10-25.
Findings
The investigation substantiated the allegation of illegal eviction due to failure to provide proper eviction notices meeting regulatory requirements, failure to notify the resident's responsible party timely, and failure to provide alternative housing resources and correct information for filing complaints. The licensee did not comply with eviction notice regulations, posing potential health, safety, and personal rights risks to the resident.
Complaint Details
The complaint investigation was substantiated. The allegation involved illegal eviction of a resident without proper notification and documentation. Interviews with witnesses, staff, and the resident confirmed inappropriate eviction procedures and lack of proper communication and documentation by the facility.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Eviction notices did not meet requirements under Health and Safety Code 1569.683, including failure to notify responsible party, lack of alternative housing resources, and incorrect ombudsman contact information. | Type B |
Report Facts
Capacity: 165
Census: 149
Plan of Correction Due Date: Nov 27, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jon McCraw | Executive Director | Met with Licensing Program Analyst during investigation and involved in eviction notice issue |
| Lori Alexander-Washington | Licensing Program Analyst | Conducted the complaint investigation visit |
| Bennett Fong | Licensing Program Manager | Oversaw licensing program and signed report |
Inspection Report
Annual Inspection
Census: 149
Capacity: 165
Deficiencies: 1
Nov 1, 2024
Visit Reason
The inspection was an unannounced Required Annual Inspection conducted to evaluate compliance with licensing regulations.
Findings
The facility was toured and observed to have adequate lighting, temperature, and safety features. One deficiency was cited related to food service requirements where a cleaning compound was found unlocked in the kitchen, posing a safety risk. The deficiency was corrected during the visit.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Comet cleaner was found unlocked in kitchen where food was being prepared, posing an immediate health, safety or personal rights risk to persons in care. | Type A |
Report Facts
POC Due Date: Nov 2, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| John McCraw | Administrator | Facility Administrator who joined the inspection |
| Ruth Hernandez-Saleh | Resident Liaison | Met with Licensing Program Analysts during inspection |
| David Doidge | Licensing Program Analyst | Conducted the inspection and signed the report |
| Bennett Fong | Licensing Program Manager | Reviewed the Emergency Disaster Plan and supervised the inspection |
Inspection Report
Annual Inspection
Capacity: 165
Deficiencies: 0
Oct 27, 2023
Visit Reason
The visit was an unannounced 1-Year Annual Required inspection conducted to evaluate the facility's compliance with licensing requirements.
Findings
No deficiencies were cited during the visit. The facility was toured, records reviewed, and various safety and operational aspects were found to be in compliance.
Report Facts
Residents records reviewed: 7
Staff records reviewed: 10
Hospice waiver residents: 6
Hot water temperature: 105
Hot water temperature: 106
Hot water temperature: 108
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jon McCraw | Executive Director | Met with Licensing Program Analyst during the inspection and involved in facility tour. |
Inspection Report
Annual Inspection
Census: 142
Capacity: 165
Deficiencies: 0
Nov 10, 2022
Visit Reason
The inspection was an unannounced 1-Year Annual Required inspection conducted to evaluate compliance with licensing requirements.
Findings
The facility was toured and inspected, including resident apartments, bathrooms, activity rooms, kitchen, and common areas. No deficiencies were cited during the visit, and all safety and comfort measures were found adequate.
Report Facts
Hallway temperature: 73
Hot water temperature: 120
Nonperishable food supply: 7
Perishable food supply: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jon McCraw | Administrator | Met with Licensing Program Analysts during inspection and participated in facility tour |
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