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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701213
Report Date: 07/26/2023
Date Signed: 07/26/2023 03:45:32 PM


Document Has Been Signed on 07/26/2023 03:45 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 SACRAMENTOFACILITY NUMBER:
342701213
ADMINISTRATOR:WIMMER, KASIEFACILITY TYPE:
740
ADDRESS:1075 FULTON AVENUETELEPHONE:
(916) 971-4800
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:185CENSUS: 146DATE:
07/26/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Kasie WimmerTIME COMPLETED:
04:00 PM
NARRATIVE
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On 7/26/23, Licensing Program Analyst (LPA) Tung Truong conducted an unannounced Case Management visit to address concerns regarding a resident's elopement on 7/23/23. LPA met with Administrator, Kasie Wimmer and explained the purpose of the visit.

Based on the incident report and review of resident's LIC 602, resident R1 has been determined to be unable to leave the facility unassisted by his physician. It was learned that R1 eloped from the facility through the rear gate of the building without staff knowledge. According to staff, R1 went out the back courtyard and went out the delayed Egress. Staff responded to the courtyard door and saw another resident by the door. Staff thought the female resident had triggered the alarm. Staff reset the alarm and the alarm also reset the Delayed Egress that was not supposed to happen. R1 was located by Management and returned to the facility where R1 was assessed to be without any injury.
Per California Code of Regulations, Title 22, deficiencies are being cited on the attached 809-D during this visit. CIVIL PENALTIES ARE ASSESSED IN THE AMOUNT OF $500 today for immediate violations.

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-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2023
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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Document Has Been Signed on 07/26/2023 03:45 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
FACILITY NUMBER: 342701213

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/27/2023
Section Cited
CCR
87705(k)(4)

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Care of Persons with Dementia: Without violating Section 87468, Personal Rights, facility staff shall attempt to redirect a resident who attempts to leave the facility.
This requirement was not met as evidenced by:
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Licensee/Administrator shall submit a written plan of correction indicating the steps the facility will take to ensure adequate supervision of residents in care to prevent future unauthorized absences from residents. Plan will be submitted to the department by the POC due date 7/27/23.
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Based on record reviews, Resident R1 who is identified as unable to leave the facility unassisted, eloped from the facility without staff knowledge which poses an immediate heath, 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) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2023
LIC809 (FAS) - (06/04)
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