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Inspection visit

Incident investigation

CARLTON PLAZA OF FREMONTLicense 0156001181 citation on this visit
1 citation recorded

Inspector’s narrative

What the inspector wrote

On 01/3/2026 at 3:00 PM, Licensing Program Analyst (LPA) P.Manalo conducted an unannounced Case Management visit regarding a self-reported death report. The facility sent in a death report on 01/14/2026. LPA met with Executive Director (ED), Gianni Amari, and explained the purpose of the visit. Death Report (LIC624A) indicated that on 01/07/2026, R1's home health nurse observed R1 unresponsive and slow breathing. Death report indicated that the cause of death is unknown. During the visit, LPA reviewed facility’s incident report/ communication log, physician’s report, admission agreement, Resident Health Identification Information, progress notes, physician notes, home health care visit forms, and R1's service plan. LPA interviewed ED and S1. Interview with ED revealed that R1 had a wound and was referred to home health services. Interview with both ED and S1 indicated that R1 was diagnosed with a stage III wound per home health nurse documentation LPA will be requesting for a death certificate. LPA may return at a later time. The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiency by POC date may result in additional Civil Penalties. Exit interview conducted, Appeal Rights and a copy of this report provided.

Citations

3 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 87303(a)Type B

    (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: The licensee did not comply with the section cited above when the licensee had items such as hoyer lifts, bed frame, bed mattress, portraits, and vacuum which poses a potential safety risk to persons in care.

  • 87309(a)Type A

    (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects...locked storage and are not left unattended if outside the locked storage.This requirement is not met as evidenced by: Based on observation and record review, the licensee did not comply with the section above by having two scissors unlocked in R1's room with a dementia diagnosis which poses an immediate safety risk to persons in care.

  • 87615(a)(1)Type B

    87615(a)(1) (a) Persons who require health services for or have a health condition including...shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries.This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above when facility retained a resident with a stage III pressure wound which posed a potential health risk to persons in care.

FAQ · About this visit

Common questions about this visit

What happened during the January 30, 2026 inspection of CARLTON PLAZA OF FREMONT?

This was a other inspection of CARLTON PLAZA OF FREMONT on January 30, 2026. 1 citation were issued: 1 Type B.

Were any citations issued to CARLTON PLAZA OF FREMONT on January 30, 2026?

Yes, 1 citation was issued (0 Type A, 1 Type B). The first citation was for: "(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of..."

What type of inspection was this?

This was a other inspection. other inspections are conducted by CCLD as part of their licensing oversight.

SourceView on CCLDView original report

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Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.