342701212-9-20-2023-27-AS-TTRG-CVUVJE-20230920162836

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342701212
Report Date: 09/20/2023
Date Signed: 09/20/2023 04:28:42 PM

Document Has Been Signed on 09/20/2023 04:28 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

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: 49	DATE:	09/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Kasie Wimmer		TIME COMPLETED:	04:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 9/20/2023, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct an annual inspection visit. LPA met with Administrator Kasie Wimmer and explained the purpose of the visit. Administrator holds certification # 6034525740 and has expired on 5/21/2023. Renewal application is currently pending. The facility is licensed to serve (99) non-ambulatory residents. Hospice waiver approved for (15). There are (49) residents in care currently. LPA toured and inspected the physical plant inside and outside to ensure there were no health and safety concerns. LPA observed the lounge area, lobby, and common areas. In addition, the kitchen areas, dining area, and activity room was toured. Medication room was toured. Kitchen was toured for adequate food supplies and storage. A review of the facility perimeter fence, side gates, and exits was conducted. A review of the resident rooms was conducted. LPA observed the facility to be free of odor, clean and in good repair. LPA observed required furniture and lighting throughout the facility. LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. The hot water temperature was measured at 122.5F in room #120 and 124.0F in room #103. The temperature inside the facility measured at 73.0 degrees Fahrenheit. LPA observed centrally stored medications, toxins, and sharp knives kept locked and inaccessible to residents. LPA observed the fire extinguisher(s) were up to date. LPA observed smoke and carbon monoxide detector(s) in the facility were in good repair. First aid kit was checked and is complete. Proof of current liability insurance was observed. Continue on 809-C

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 ATRIUM	FACILITY NUMBER: 342701212
	VISIT DATE: 09/20/2023

NARRATIVE

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LPA requested resident and staff files for review. LPA reviewed (3) resident files and (3) staff files, including criminal record clearances. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. LPA verified staff training for staff file reviews.

The following documents was obtained during today's visit:
LIC 308 Designation of Administrative Responsibility, Administrator Certificate, and Proof of current Liability Insurance.

The following forms and documents were requested to be submitted within 15 days: LIC 500 Personnel Report, LIC 610 Emergency Disaster Plan.

Per California Code of Regulations, Title 22, deficiencies are being cited on the attached 809-D during this visit.

Exit interview was conducted, a copy of this report, LIC 809-D and Appeal Rights were left at the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/20/2023 04:28 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: CARLTON SENIOR LIVING SACRAMENTO ATRIUM	FACILITY NUMBER: 342701212
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

87303 Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows:(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on measurement of the water temperature, the licensee did not comply with the section cited above. Water temperature was measured 122.5F. in rm#120 and 124.0F in rm#103. This poses an immediate health and safety risk to residents in care.
	POC Due Date: 09/25/2023
	Plan of Correction
1 2 3 4	Administrator shall reduce hot water temperature to the required 105-120 degree range by POC date. Water was adjusted during the inspection. Administrator shall also submit a water temperature log to CCL with temperature logs for rooms 103 and 120 for three consecutive days by 9/23/23.

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.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023

LIC809 (FAS) - (06/04)

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