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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000295
Report Date: 05/04/2022
Date Signed: 05/04/2022 12:31:09 PM


Document Has Been Signed on 05/04/2022 12:31 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:KARLTON RESIDENTIAL CARE CENTERFACILITY NUMBER:
306000295
ADMINISTRATOR:ELENA WEINERFACILITY TYPE:
740
ADDRESS:3615 WEST BALL RD.TELEPHONE:
(714) 236-1170
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:76CENSUS: 45DATE:
05/04/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Elena WeinerTIME COMPLETED:
11:50 AM
NARRATIVE
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Licensing Program Analysts (LPAs) Kimberly Lyman and Joseph Alejandre conducted an unannounced case management visit to follow up on an incident report submitted to the department on 04/20/2022. LPAs were greeted and granted entry into the facility by Administrator Elena Weiner and explained the reason for the visit.

Incident report dated 04/20/2022 indicate Resident 1 was found at Starbucks by Starbucks employees and 911 was called around 6 AM. Anaheim Police responded and notified facility resident was found. R1 was sent out to West Anaheim Medical Center for an evaluation and returned with medication changes. R1 had a one on one caregiver upon return. Resident was sent out the next day to Chapman Global Medical Center for a psychiatric evaluation and returned 05/03/2022 on hospice care. LPAs observed R1 during the visit. Resident appears safe and has a care companion with the resident. Investigation conducted by facility indicated that the resident took a folding chair from the entrance of facility and exited onto the front patio. Resident removed the alarm on the door. Resident climbed over the front gate using the chair for assistance and was then discovered at Starbucks, approximately .9 miles away. Facility has subsequently removed the folding chair from the entrance. Administrator indicated that there were three staff on shift at the conclusion of the NOC shift around 6 AM.
Physician report dated 01/31/2022 indicated a diagnosis of Dementia with a history of wandering behavior.

Based on the observations made during today's visit, the following violations are being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report as well as appeal rights were discussed and provided with facility representative.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/04/2022 12:31 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: KARLTON RESIDENTIAL CARE CENTER
FACILITY NUMBER: 306000295

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/05/2022
Section Cited

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Basic services shall at a minimum include:
Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code
section 1569.2(c). This requirement is not being met as evidenced by:
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Based on interview and record review, Licensee failed to ensure R1 was provided care and supervision. R1 eloped out of the facility and was discovered by Starbucks staff approximately .9 miles away. This poses an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2022
LIC809 (FAS) - (06/04)
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