342700988-12-6-2021-27-AS-KHOS-C9QQKN-20211215111438

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700988
Report Date: 12/06/2021
Date Signed: 12/06/2021 11:57:19 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/17/2021 and conducted by Evaluator Kevin Gould

COMPLAINT CONTROL NUMBER: 27-AS-20210917091513

FACILITY NAME:	CARLTON SENIOR LIVING SACRAMENTO		FACILITY NUMBER:	342700988
ADMINISTRATOR:	CARO, MARYBEL		FACILITY TYPE:	740
ADDRESS:	1071 & 1075 FULTON AVENUE		TELEPHONE:	(925) 370-6220
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95825
CAPACITY:	284	CENSUS: 175	DATE:	12/06/2021
		UNANNOUNCED	TIME BEGAN:	10:05 AM
MET WITH:	Marybel Caro		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Physical Plant: Facility Has Bedbugs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kevin Gould made an unannounced inspection to the Carlton Senior Living Sacramento RCFE on 12/6/21 at 10:00am to conclude the investigation of the above allegation and to deliver the findings. LPA met with Administrator and together discussed the investigation details.

Based on the interviews and statements obtained during the investigation process, the allegations have been corroborated. LPA conducted interviews with 7 staff members (see confidential names list, LIC 811 dated 12/6/21). Additionally, LPA interviewed R1, A1 and A2 and A3. Based on the interviews and statements received from S1, S2, R1, A1, A2, and A3; this complaint has been substantiated because the facility, at the families request, delayed the pest control treatments for R1's bedroom and creating a potential health, safety and personal rights risk to staff and other residents in the facility.

Report continued on LIC 9099-C. Page 1 of 2.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2021

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 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/17/2021 and conducted by Evaluator Kevin Gould

COMPLAINT CONTROL NUMBER: 27-AS-20210917091513

FACILITY NAME:	CARLTON SENIOR LIVING SACRAMENTO		FACILITY NUMBER:	342700988
ADMINISTRATOR:	CARO, MARYBEL		FACILITY TYPE:	740
ADDRESS:	1071 & 1075 FULTON AVENUE		TELEPHONE:	(925) 370-6220
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95825
CAPACITY:	284	CENSUS:	DATE:	12/06/2021
		UNANNOUNCED	TIME BEGAN:	10:05 AM
MET WITH:	Marybel Caro		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Personal Rights: Staff did not ensure that resident had access to her wheelchair.
Neglect/Lack of Supervision: Staff left residents unsupervised for an extended period of time.
Physical Plant: Staff did not keep residents' carpets clean.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kevin Gould made an unannounced inspection to the Carlton Senior Living Sacramento RCFE on 12/6/21 at 10:00am to conclude the investigation of the above allegations and to deliver the findings. LPA met with Administrator and together discussed the investigation details.

Based on the interviews and statements obtained during the investigation process, the allegations cannot be substantiated. LPA conducted interviews with 7 staff members, R1, A1, A2 and A3 (see confidential names list, LIC 811 dated 12/6/21). Based on the interviews conducted LPA determined that the facility did provide R1 with a wheelchair. Although R1's preferred wheelchair needed to remain the affected room for treatment, statements from all staff interviewed indicated a wheelchair was provided R1. This allegation is unsubstantiated.

Report continued on LIC 9099-C. Page 1 of 2.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2021

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

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 27-AS-20210917091513

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: CARLTON SENIOR LIVING SACRAMENTO	FACILITY NUMBER: 342700988
	VISIT DATE: 12/06/2021

NARRATIVE

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Regarding allegations or R1 being left unsupervised for extended period of time; LPA could not obtain enough information to corroborate the allegation took place. LPA interviewed R1 who could not identify a specific date, time of day or staff who allegedly left R1 unsupervised while needing assistance with transferring. LPA attempted to gather additional information from staff but was unable to identify any instances of a lack of supervision. This allegation is unsubstantiated.

LPA also attempted to corroborate the allegation R1's carpet was dirty. LPA was unable to verify if R1's carpet in their former room was dirty, as the room was already being renovated and new carpet had been installed as the facility was preparing the room for a new resident. Staff interviewed who regularly cared for R1 did not observe the carpet to be dirty or stained. This allegation is unsubstantiated.

Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed.

There are no deficiencies noted or cited per California Code Regulation, TITLE 22.

Exit interview was conducted with the facility administrator. Appeal Rights were issued, and a copy of this report was left at the facility.

Page 2 of 2.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 27-AS-20210917091513

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: CARLTON SENIOR LIVING SACRAMENTO	FACILITY NUMBER: 342700988
	VISIT DATE: 12/06/2021

NARRATIVE

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The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of Physical Plant is substantiated but if any additional information is received this complaint can be amended and the finding can be changed.

The following deficiencies are cited per California Code Regulation, TITLE 22.

Exit interview was conducted with the facility administrator. Appeal Rights were issued, and a copy of this report was left at the facility.

Page 2 of 2.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 27-AS-20210917091513

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: CARLTON SENIOR LIVING SACRAMENTO	FACILITY NUMBER: 342700988
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/06/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/13/2021 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	Maintenance and Operation : 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 was not met as evidenced by the facility delaying	1 2 3 4 5 6 7	Facility will add an addendum to their admission agreement that stipulates any pest control services that may be necessary in the facility must be conducted at the earliest opportunity to prevent pest infestation from impacting other residents, staff and visitors.
	8 9 10 11 12 13 14	pest control services at the request of a resident and therefore creating a potential health, safety and personal rights risk for residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2021

LIC9099 (FAS) - (06/04)

Page: 5 of 5