342700988-4-18-2022-27-AS-KHOS-CDWJFY-20220428070132

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700988
Report Date: 04/18/2022
Date Signed: 04/18/2022 12:33:04 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, 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
01/07/2022 and conducted by Evaluator Christopher Hopkins-Clarke

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20220107092408

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: 183	DATE:	04/18/2022
		UNANNOUNCED	TIME BEGAN:	11:04 AM
MET WITH:	Marybel Caro		TIME COMPLETED:	12:40 PM

ALLEGATION(S):

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-Staff did not notice residents change in condition
-Staff did not ensure resident's oxygen was on at all times
-Staff did not follow Physician's orders for oxygen

INVESTIGATION FINDINGS:

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On April 18, 2022 at 11:00am, Licensing Program Analyst (LPA) Chris Hopkins conducted an unannounced facility visit in regards to a complaint investigation with the above allegations. LPA met with Administrator Marybel Caro and explained the purpose of today's visit.

Regarding the allegation of Staff did not notice residents change in condition, the Department found the following: based on interview and record review, it was determined that staff noticed Resident 1 (R1) was not looking like his/her self during their routine check of R1. Staff immediately called the Director of Resident Services, who then called Emergency Medical Services (EMS), who transferred R1 to the hospital.

Regarding the allegation of Staff did not ensure resident's oxygen was on at all times, the Department found the following: based on interview, it was determined that R1's oxygen stayed on her face at all times. During one occasion staff had to give R1 a sponge bath and had to temporarily remove the oxygen to move the resident. Report continued on LIC9099-C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Christopher Hopkins-Clarke	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2022

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 4

Control Number 27-AS-20220107092408

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: 04/18/2022

NARRATIVE

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The oxygen tube did roll under R1's bed wheel causing it to get "crimped" and not flow. Staff did not notice the long tube "crimped" under the bed during the time of R1 getting a sponge bath, but minutes later R1's visitor notified staff and staff immediately fixed the tubing. Staff stated that R1 always had oxygen on, and staff knew to put/keep oxygen on R1.

Regarding the allegation of Staff did not follow Physician's orders for oxygen, the Department found the following: based on interview and record review, it was determined that staff were able to remove oxygen to perform the nebulizer treatment. In doing the nebulizer treatment staff had the option of removing the oxygen or leaving it on. Per R1's physician, he stated that while doing nebulizer treatment it doesn't matter if oxygen is on or off, either way is ok. This was the only time the oxygen was off, even though the physician order stated oxygen at all times, R1's physician stated it was ok to remove oxygen during the nebulizer treatment.

LPA has deemed the three allegations mentioned above as UNSUBSTANTIATED. Although the allegations may have happened and/or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted with Administrator Marybel Caro. A copy of this report was left with Administrator upon exit.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Christopher Hopkins-Clarke	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
01/07/2022 and conducted by Evaluator Christopher Hopkins-Clarke

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20220107092408

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: 183	DATE:	04/18/2022
		UNANNOUNCED	TIME BEGAN:	11:04 AM
MET WITH:	Marybel Caro		TIME COMPLETED:	12:40 PM

ALLEGATION(S):

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-Staff are not answering call buttons timely

INVESTIGATION FINDINGS:

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On April 18, 2022 at 11:00am, Licensing Program Analyst (LPA) Chris Hopkins conducted an unannounced facility visit in regards to a complaint investigation with the above allegations. LPA met with Administrator Marybel Caro and explained the purpose of today's visit.

Regarding the allegation of Staff are not answering call buttons timely, the Department found the following: based on record review, it was determined that staff were not answering call buttons in a timely manner. LPA reviewed the call log and observed staff response time for R1 and there were multiple response times of 15 minutes or higher.

Based on record review, the preponderance of evidence standards has been met, therefore, the above allegation(s) is/are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 9099D during this visit. Exit interview held, Appeal Rights discussed and given, Copy of report given.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Christopher Hopkins-Clarke	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2022

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

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 27-AS-20220107092408

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: 04/18/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/19/2022 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	87468.1(a)(2)Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator has agreed to formulate a plan of action to ensure that all residents receive timely responses when call pendants are pressed. Proof of action plan to be sent to CCLD by POC date.
	8 9 10 11 12 13 14	Based on record review the Licensee did not ensure that Resident 1 received timely responses when the call pendant was pressed. This poses a immediate health and safety risk to 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: Christopher Hopkins-Clarke	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2022

LIC9099 (FAS) - (06/04)

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