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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701212
Report Date: 06/12/2024
Date Signed: 06/12/2024 10:38:04 AM

Substantiated


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
06/10/2024 and conducted by Evaluator Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20240610125348
FACILITY NAME:CARLTON SENIOR LIVING SACRAMENTO ATRIUMFACILITY NUMBER:
342701212
ADMINISTRATOR:KASIE WIMMERFACILITY TYPE:
740
ADDRESS:1071 FULTON AVENUETELEPHONE:
(916) 971-4800
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:99CENSUS: 53DATE:
06/12/2024
UNANNOUNCEDTIME BEGAN:
08:58 AM
MET WITH:Kasie WimmerTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Medication: Staff did not properly dispose of used needle.
INVESTIGATION FINDINGS:
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On 6/12/24 at 9:00am Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced complaint inspection at Carlton Senior Living Sacramento Atrium RCFE to inform the licensee of complaint allegation mentioned above.

Based on the interviews and statements obtained during the investigation process, the allegations are substantiated because LPA Gould interviewed two staff members who confirmed that an LVN staff member administered insulin to a resident and did not remove the needle in accordance with regulations. A PM staff member who attempted to administer medications at a later time was confirmed to be bricked by the exposed needle that was not disposed of according to regulations.

The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of Medications is substantiated.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
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-20240610125348
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: 06/12/2024
NARRATIVE
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The following deficiency is cited per California Code of Regulations, TITLE 22.

Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the home.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 27-AS-20240610125348
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/14/2024
Section Cited
CCR
87303(f)(2)
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Maintenance and Operation: Syringes and needles are disposed of in accordance with the California Code of Regulations, Title 8, Section 5193 concerning bloodborne pathogens. This requirement was not met as evidenced by statements from staff members
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Facility has conducted in service training for staff members who assist residents with injections and training will be conducted quarterly to ensure staff meet regulations.
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 confirming needle was not disposed of according to regulations resulting in a staff member finger prick which poses a potential health safety and personal rights risk to residents in care.
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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-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3