577005341-9-24-2026-21-AS-KMOA-DYNUSF-20261008155016

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 577005341
Report Date: 09/24/2026
Date Signed: 09/24/2026 01:49:30 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/17/2026 and conducted by Evaluator Jill Nakagawa

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20260717123132

FACILITY NAME:	CARLTON PLAZA OF DAVIS		FACILITY NUMBER:	577005341
ADMINISTRATOR:	BLAINE LYONS		FACILITY TYPE:	740
ADDRESS:	2726 5TH STREET		TELEPHONE:	(530) 564-7002
CITY:	DAVIS	STATE: CA	ZIP CODE:	95618
CAPACITY:	150; 150	CENSUS: 140	DATE:	09/24/2026
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Blaine Lyons, Administrator		TIME COMPLETED:	11:22 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Neglect/Lack of supervision resulting in injury
Facility in disrepair

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Nakagawa arrived unannounced on 9/24/2026 to conduct a complaint investigation regarding the above allegations. LPA met with Administrator Blaine Lyons to discuss the findings.

The complaint alleges that Neglect/Lack of supervision resulted in injury. The complainant stated that the resident (R1) fell in the memory care courtyard but staff were unable to locate. LPA conducted an inspection of the facility and found that the location of the resident’s (R1) fall in the memory care courtyard was off the walkway and down a small easement in the landscaping making R1 undetected due to their location being obscured by bushes and shrubs. R1 remained undiscovered despite the staff stating they checked the courtyard several times.

(Continued on 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2026

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 2

Control Number 21-AS-20260717123132

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: CARLTON PLAZA OF DAVIS	FACILITY NUMBER: 577005341
	VISIT DATE: 09/24/2026

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

(Continued from 9099)

R1 remained undiscovered despite the staff stating they checked the courtyard several times. R1 was ultimately found by police, who called emergency services to assess R1. R1 was found to have no injuries other than a small scrape. R1 did not require medical attention and remained at the facility. Based on resident records and police report the allegation that Neglect/Lack of Supervision resulted in injury is Unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

During LPA's complaint investigation inspection LPA opened a case management (See LIC 809 dated 09/24/2026) regarding the care and supervision of resident R1.

In addition, the complaint alleges that the facility is in disrepair. The complainant states that the facility’s cameras were not operational. Cameras monitoring the outside of the gates of memory care unit were operational, as were the outdoor alarms for both the exit door to the courtyard and the delayed egress gates as per facility’s plan of operation. LPA found that cameras in the courtyard area are not listed as part of facility’s operations. Based on the plan of operations the cameras covering the memory care courtyard are not part of the plan of operation therefore their lack of use does not constitute disrepair, and so LPA found that the allegation that facility was in disrepair is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 2