342701212-8-25-2025-27-AS-LKIG-DKSVLN-20250822163211

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342701212
Report Date: 08/22/2025
Date Signed: 08/25/2025 08:36:01 AM

Document Has Been Signed on 08/25/2025 08:36 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
ADMINISTRATOR/ DIRECTOR:	KASIE WIMMER		FACILITY TYPE:	740
ADDRESS:	1071 FULTON AVENUE		TELEPHONE:	(916) 971-4800
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95825
CAPACITY: 99		CENSUS: 50	DATE:	08/22/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:30 AM
MET WITH:	Cal Mendiola and Kasey Wimmer		TIME VISIT/ INSPECTION COMPLETED:	04:30 PM

NARRATIVE

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Licensing Program Manger (LPM) Liza King and Licensing Program Analysts (LPA) Noel Wolf Petersen arrived at this facility unannounced to conduct a Required 1 Year Annual Inspection Visit. LPm was met by Executive Ast and administrator joined 30 minutes later. LPM explained the purpose of the visit to Administrator and Executive Ast. Facility currently has 6 residents receiving home health, 7 residents on hospice, 5 residents use a hoyer lift. Staffing on average is Am shift 2 MedTechs(MT) and 7 caregivers (CG) PM shift 5 CG and 1 MT and overnight shift 3CG and 1MT.

LPM and Executive Ast inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry area, living area and other common areas, as well as outside of the facility to ensure compliance with Title 22 regulations. Throughout the day LPM and LPA observed breakfast and lunch service, exercise program, neighborhood walking groups, bingo and painting and fresh popcorn service.

Chemicals and medications noted to be locked to residents in care. Residents rooms did contain various personal care products and cleaning supplies which could pose a risk to those clients that wander throughout the facility. No bodies of water were observed at the facility.

cont.

NAME OF LICENSING PROGRAM MANAGER: Krystall Moore
NAME OF LICENSING PROGRAM ANALYST: Liza King
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/22/2025

NARRATIVE

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Hot water temperature was measured at 107 F degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees Fahrenheit. All necessary documents were in place. LPM observed the all necessary posters on the facility wall: incl but not limited to Facility license, See Something Say Something poster, Ombudsman poster, Rights of Resident/Family Councils.
LPM reviewed 7 resident files (3 of which were on hospice) all medical assessments and care plans appear to be up to date. Additional documentation reviewed included Hospice documentation and daily notes, Centrally Stored medications lists, MARS, and admissions required documents. R6 during the month of July 2025 went without a medication for heart failure for 3 consecutive days and during Aug 2025 the resident went without the same medication for 8 consecutive days and counting. A discussion occured and an explanation was provided that the medication is not covered by the resdients current medical provider, no alternative means have been identified. A Citation will be issued. The facility has recently changed to a new EHR system.
LPM toured the facility during breakfast service and again in the afternoon to observe repairs that have been made. During the morning tour, LPM observed: A tour of the kitchen revealed unlabeled foods in the Refrigerator, freezer and pantry. The seal on the door of the freezer was not working properly causing food to be freezer burned and damaged. Additionally a flickering light was obsereved in the hall, multiple screens had holes and the elevator was broken. A repeat tour was conducted and all items were repaired except the flickering light on the hall and screens, technical assistance provided.

A citation was issued during todays annual inspoection related to medication administration, an exit interview was conducted with Kasey Wimmer and Appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Krystall Moore
NAME OF LICENSING PROGRAM ANALYST: Liza King
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/25/2025 08:36 AM - It Cannot Be Edited

Created By: Liza King On 08/22/2025 at 03:48 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: CARLTON SENIOR LIVING SACRAMENTO ATRIUM	FACILITY NUMBER: 342701212
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(a)(4)

Incidental Medical and Dental Care Services

(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on a review of 1of7 resdient files the licensee did not comply with the section cited above in which R6 during the month of July 2025 went without a medication for heart failure for 3 consecutive days and during Aug 2025 the resident went without the same medication for 8 consecutive days and counting. A discussion occured and an explanation was provided that the medication is not covered by the resdients current medical provider, no alternative means have been used which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/22/2025
	Plan of Correction
1 2 3 4	Thelicensse will have the hospice agency review the medications if the medications are needed they licensee will order from their contracted pharmacy. Will send proff of communications such as service notes or fax documentation to Kimberly,Viarella@dss.ca.gov

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Krystall Moore
NAME OF LICENSING PROGRAM MANAGER:

	Liza King
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2025

LIC809 (FAS) - (06/04)

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