435200727-1-16-2026-26-AS-CKAI-DUV2HR-20260608172510

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435200727
Report Date: 01/16/2026
Date Signed: 01/16/2026 02:11:40 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/20/2025 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20251020085128

FACILITY NAME:	CARLTON PLAZA OF SAN JOSE		FACILITY NUMBER:	435200727
ADMINISTRATOR:	SHANTELA YADAO		FACILITY TYPE:	740
ADDRESS:	380 BRANHAM LANE		TELEPHONE:	(408) 972-1400
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95136
CAPACITY:	183	CENSUS: 96	DATE:	01/16/2026
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Shantela Yadao		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff did not address the resident's change in condition.
Staff are not meeting resident's medical needs.
Staff are not meeting resident's dietary needs.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Administrator (ADM) Shantela Yadao. On 10/20/2025, the department received a complaint with the above allegations. On 10/29/2025, LPA Marrufo conducted an initial complaint investigation visit.

Allegation - Staff did not address the resident's change in condition. - UNFOUNDED

R1’s Physician’s Report has an examination date of 06/23/2025. R1’s Physician’s Report states R1 had a diagnosis of “Acute Left basal ganglia stroke.”

R1’s Service Plan is dated 06/26/2025. It states R1’s Move-in Date is 06/23/2025. R1’s Service Plan identifies R1’s diagnosis as “Basal Ganglia Stroke.” R1’s Service Plan states R1’s needs include continence care, dressing assistance, medication management, shower assist, and special diet. See LIC9099-C page for more information. Page 1 of 3.

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 26-AS-20251020085128

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: CARLTON PLAZA OF SAN JOSE	FACILITY NUMBER: 435200727
	VISIT DATE: 01/16/2026

NARRATIVE

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During interview on 10/29/2025, resident R1 stated to have not experienced a change in condition since arriving at the facility.

During interview on 01/16/2026, ADM stated that R1 had already suffered a stroke prior to being admitted to the facility.

Allegation - Staff are not meeting resident's medical needs. - UNFOUNDED

During interview on 10/29/2025, R1 stated to regularly refuse medications.

During interview on 10/29/2025, staff S1, a medication technician, stated that he/she has been assigned to provide R1 with medication during both morning and night shifts. S1 stated he/she has asked R1 if R1 has taken his/her medications, and R1 will say, “No.” S1 stated he/she will ignore S1 or say the medications are “nasty.” S1 stated the staff will document that R1 refused the medication and the medication was discarded.

R1’s Medication Administration Record (MAR) from September 2025 states R1 refused medications from 09/01/2025 to 09/09/2025 and was out of the facility from 09/13-15/2025. R1’s MAR from October 2025 states R1 refused medications on 10/04/2025 and from 10/06/2025 to 10/20/2025.

The entries 10/06/2025, 10/07/2025, 10/19/2025, and 10/20/2025 state, “MD/RP notified.” The entries for 10/11/2025 and 10/13/2025 have notes that state, “refused after multiple attempts.” The entries from 10/17/2025 have notes that state, “resident stated [he/she] didn’t want to take [his/her] medications, when asked for a reason why [he/she] doesn’t want medications [he/she] turned away and ignored my questions.” The entries on 10/20/2025 have notes that state, “Resident stated ‘I choose to be free.’”

During interview on 01/16/2026, ADM stated R1 refuses staff services and care.

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SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20251020085128

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: CARLTON PLAZA OF SAN JOSE	FACILITY NUMBER: 435200727
	VISIT DATE: 01/16/2026

NARRATIVE

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Allegation - Staff are not meeting resident's dietary needs. - UNFOUNDED

R1’s Physician’s Report states R1’s Special Diet is “No Added Salt (NAS) diet, Mechanical Soft, Thin.” R1’s Physician’s Report states R1 can feed himself/herself.

R1’s Service Plan states R1 “will be offered a mechanical soft diet.”

The Special Diet Board, dated 07/03/2025, includes the names and photographs of residents with dietary needs of residents who have special diets. R1’s name, photograph, and apartment number are shown along with the note “Mechanical Soft.”

During interview on 10/29/2025, R1 stated that he/she does not need assistance with feeding. R1 stated staff assist him/her with feeding. R1 stated he/she regularly refuses to eat.

R1’s Daily Log records R1 refused meals on 10/09/2025 and 10/12/2025.

On 10/29/2025, LPA Marrufo interviewed S2, lead wait staff. S2 stated he/she picks up food from R1 after meals. S2 stated R1 sometimes refuses meals.

During interview on 01/16/2026, ADM stated staff ask R1 if they can help with feeding him/her, but R1 tells staff to leave the food next to him/her and he/she will eat it later.

This agency has investigated the complaint allegations listed. Based on interviews and review of records, the CCLD has found that the complaint allegations are UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

This report was reviewed with Administrator Shantela Yadao and a copy of this report was provided.

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END REPORT

SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2026

LIC9099 (FAS) - (06/04)

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