342701213-9-20-2022-27-AS-CYAG-CJFMTT-20220920095401

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342701213
Report Date: 09/16/2022
Date Signed: 09/20/2022 09:54:08 AM

Document Has Been Signed on 09/20/2022 09:54 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	CARLTON SENIOR LIVING SACRAMENTO		FACILITY NUMBER:	342701213
ADMINISTRATOR:	WIMMER, KASIE		FACILITY TYPE:	740
ADDRESS:	1075 FULTON AVENUE		TELEPHONE:	(916) 971-4800
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95825
CAPACITY:	185	CENSUS: 170	DATE:	09/16/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Kasie Wimmer		TIME COMPLETED:	12:30 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	Unannounced prelicensing visit made out to this facility on 09/16/2022 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator Kasie Wimmer. Brief interview was conducted with the facility designated Administrator Kasie Wimmer and Emanuel "Manny" Dirar. It was learned that there were (3) residents under the care of hospice at this time. This facility has a hospice waiver to accept and retain up to 20 residents at any given time. It was learned that there were 16 residents receiving services through home health at this time. It was learned that there were (4) residents who were deemed to be bedridden at this time. Current census was 170 residents. Tour of this facility was conducted alongside the facility designated Administrator Kasie Wimmer and Emanuel Dirar. Kitchen area was toured. Food storage units were reviewed for adequate temperatures in the refrigerator and freezer. A review of the food supply was conducted for adequate 2-day perishable and 7-day nonperishable quantities at all times. It was learned that deliveries were made out to this facility at least twice a week by the contracted vendors. Living area, dining area, and all other areas intended for resident use were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. Medication room was observed to be locked and made inaccessible to the residents at this time. Policies and procedures were discussed with the medication technician who was present at this time. First aid kit was observed to be present and contained all of the required components. Fire extinguishers, located throughout this facility, were observed to have been annually inspected on 01/18/2022 by the local fire extinguisher company, Cintas, and in compliance at this time. Laundry areas were toured. It was learned that residents, who were deemed able to do so per their Physicians Report (LIC 602), were able to perform their own laundry duties storing laundry detergent and bleach as needed. Activities room was toured. It was observed that activities supplies were sufficient and able to meet

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022

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	FACILITY NUMBER: 342701213
	VISIT DATE: 09/16/2022

NARRATIVE

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the needs of the residents at this time. A monthly calendar was observed to be posted as well.
A tour of the resident rooms was conducted for the first and second floor of this facility.
This LPA activated the emergency pull cord in a resident restroom to gauge the response time of the staff and to make sure that this system was active and functional at this time.
Exterior grounds of this facility was toured.
A review of the facility perimeter fence, side gates, and exits was conducted.
Memory care unit was toured. A review of the resident rooms was conducted. Resident furniture and furnishings were observed to be sufficient and in good repair at this time.
Resident restrooms were toured. Grab bars and non skid surfaces were observed to be present and in good repair at this time. Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees.
Exterior courtyard for this memory care unit was properly fenced with delayed egress at the gate.

This facility, and its Applicant, has been found to be in compliance at this time.

Exit Interview

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022

LIC809 (FAS) - (06/04)

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