342701212-1-15-2025-27-AS-KHOS-DD6KJ2-20250122065602

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701212
Report Date: 01/15/2025
Date Signed: 01/15/2025 02:56:03 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/10/2024 and conducted by Evaluator Victoria Brown

COMPLAINT CONTROL NUMBER: 27-AS-20240910153451

FACILITY NAME:	CARLTON SENIOR LIVING SACRAMENTO ATRIUM		FACILITY NUMBER:	342701212
ADMINISTRATOR:	KASIE WIMMER		FACILITY TYPE:	740
ADDRESS:	1071 FULTON AVENUE		TELEPHONE:	(916) 971-4800
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95825
CAPACITY:	99	CENSUS: 48	DATE:	01/15/2025
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Kasie Wimmer		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff mismanaged resident medication
Staff did not obtain a hospice care plan for resident
Staff did not maintain a comfortable temperature for resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conclude the investigation of the above mentioned allegations on 1/15/25 at 8:45am. LPA met with Jose Bernales, Maintenance Manager and stated the purpose of the visit. Administrator Kasie Wimmer arrived within 20 minutes to assist with todays visit.
Regarding allegation, "Staff mismanaged resident medication" LPA conducted a review of R1's Physician Report (LIC602) dated 12/26/23 which indicates a prescribed medication called DiazePAM (Valium) 5mg oral tab (1 tab by mouth 1 hr before procedure for 1 dose).

LPA observed the Suncrest Hospice Comfort Kit Orders dated 7/18/24 which included morphine 20mg/ml solution 0.5ml (10mg) by mouth/sublingual every hour as needed for pain/shortness of breath.
There was also Seroquel (Quetiapine) 50mg tabs ordered for 1 tab in AM and 1.5 tab at bedtime and 1 tab every 4hrs as needed (PRN) and 1 tab now per instructed then it was changed to 2 tabs (100mg) 2 times a day on 7/19/24.

Unfounded

Estimated Days of Completion: 120

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 01/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025

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 27-AS-20240910153451

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CARLTON SENIOR LIVING SACRAMENTO ATRIUM	FACILITY NUMBER: 342701212
	VISIT DATE: 01/15/2025

NARRATIVE

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According to the Suncrest Hospice Sacramento Certification and Plan of Care it indicates that Valium 5mg was prescribed to Resident #1 (R1) on 7/18/24 to take 1 tab orally once a day for muscle spasms which was discontinued on 7/19/24.
LPA observed the Medication Administration Record (MAR) for July 2024 and Physician orders which contained changes to medication list. LPA observed that with PRNs the facility documentation has a comment section where staff would input a purpose for the PRN administration. After R1 returned to the facility on the evening of 7/18/24 from the hospital, R1 returned with medication changes. These medications were administered on 7/19/24 by facility staff and on 7/20/24 the Responsible Party was in possession of all R1s medication.

In addition, facility conducts medication audits randomly and on every shift the narcotics are counted and
logged as well as routine centrally stored medications are counted once received and sometimes randomly. LPA observed the narcotics count log which appears to show medication accounted for and logged.
Based on records review and interviews, LPA did not observe a preponderance of evidence standard that facility mismanaged medication for R1.

Regarding allegation, "Staff did not obtain a hospice care plan for resident" a review of resident file and hospice records revealed that R1 was admitted to Snowline Hospice on 5/24/24. Per the Case Conference Summary report dated 6/6/24 and 6/20/24 changes were made to the service plan and reassessment of eligibility was conducted. LPA observed that per the Patient Schedule R1 was transferred from Snowline Hospice to Suncrest Hospice on 7/18/24 where there was an initial visit by hospice staff, then 7/19/24 there were 3 follow-up visits, another visit on 7/20/24, and the last visit was conducted on 7/21/24 by a chaplain. Suncrest Hospice Skilled Nursing Visit Notes indicated that R1 Responsible Party gave preference regarding hospitalization and spiritual and all other concerns on 7/18/24. An interview with the Administrator revealed that R1 Responsible Party wanted to change hospice agencies from Snowline to Suncrest and initiated the change after which time the Licensee received the care plan from Suncrest and spoke with the RP regarding implementing the plan. Based on the process of receiving hospice services, traditionally, the resident may be declining, facility speaks with family and doctor, physician and hospice meet, then the RP and hospice meet to create a plan, then the facility and Responsible Party discuss it to ensure the plan can and will be implemented. Based on records review and interviews, LPA did not observe a preponderance of evidence standard that facility did not obtain a hospice care plan.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 01/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20240910153451

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CARLTON SENIOR LIVING SACRAMENTO ATRIUM	FACILITY NUMBER: 342701212
	VISIT DATE: 01/15/2025

NARRATIVE

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Regarding allegation, "Staff did not maintain a comfortable temperature for resident" LPA observed a work order for 6/5/24 which R1 Responsible Party stated the air conditioner was not working. A work order was created, however, when maintenance checked the unit the cold air button was not pushed as the unit was in working condition. LPA and Administrator conducted a unit test during this visit and the unit in the same room was operating correctly. An interview conducted with Staff #3 (S3) during todays visit revealed that the room units are replaced when broken, and service is conducted for common area units. Based on observation, records review and interviews, LPA did not observe a preponderance of evidence standard that facility did not maintain a temperature in the facility that is in accordance with the regulations.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited.

“This agency has investigated the complaint alleging the above mentioned allegations. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.”

Exit interview held, and a copy of todays’ report provided.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 01/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025

LIC9099 (FAS) - (06/04)

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