342701213-9-17-2026-27-AS-APAA-DY7MFY-20260923093506

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701213
Report Date: 09/17/2026
Date Signed: 09/17/2026 02:02:58 PM

Unsubstantiated

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
06/18/2026 and conducted by Evaluator Sulma Lopez

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20260618143811

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: 135	DATE:	09/17/2026
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Administrator Kasie Wimmer		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff did not provide resident(s) with their medications as prescribed.
Staff did not ensure that resident(s) medication(s) were refilled in a timely manner.
Staff are not ensuring medications are not left unattended.
Staff are not ensuring that residents are taking their medications.

INVESTIGATION FINDINGS:

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On September 17, 2026, at 1:00 PM, Licensing Program Analyst (LPA) Sulma Lopez arrived unannounced at the facility to deliver complaint findings. LPA Lopez met with Administrator (A1) Kasie Wimmer and explained the purpose of the visit.

On July 6, 2026, the Department received a complaint with the following allegations:

Allegation: Staff did not provide resident(s) with their medications as prescribed.
It was alleged that the facility staff did not provide resident(s) with their medications as prescribed. Throughout the investigation, the LPA toured the facility, conducted interviews, and reviewed facility documentation. The LPA conducted a tour of the facility’s medication room, which contained computers and telephones for Medicine Technicians to track prescription changes and communicate with pharmacies when ordering refills. Continued on LIC 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Sulma Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20260618143811

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	FACILITY NUMBER: 342701213
	VISIT DATE: 09/17/2026

NARRATIVE

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Interviews with Medicine Technicians indicated that procedures are in place for monitoring resident prescriptions. Medicine Technicians reported that they review medication orders daily prior to dispensing medications. Daily procedures also include checking electronic files for new prescriptions and medication stop orders, and monitoring supply levels to ensure refills are ordered on time.

A record review of residents' Medication Administration Records (MAR) sheets showed that prescription orders are clearly outlined for Medicine Technicians to follow when administering medications. The LPA observed that each medication entry listed the name of the medication, dosage, instructions, administration times, the prescribing physician, start date, and reason for use. The LPA also observed specific instructions, such as “given every 7 days” and “given with food,” clearly written on medications that required special administration procedures. LPA observed that medications that had been stopped by physicians have a "discontinued" icon next to the medication to ensure that Medicine Technicians know not to dispense the medication any longer. Based on the information gathered, there is not sufficient evidence to prove that the facility does not provide resident(s) with their prescribed medications.

Allegation: Staff did not ensure that resident medication were refilled in a timely manner.
It was alleged that facility staff do not refill medications in a timely manner. A tour of the medication room revealed that the facility stores overflow medications (up to 1 month supply) in a storage room within the medication room for each resident to prevent refill delays. LPA observed bubble packs, pill bottles, and boxes of unopened medication with resident names, medication name, doses, reason for use, dosing instructions, and expiration dates listed on them. Interviews with Medication Technicians revealed that those medications were overflow and utilized when the medications in the carts ran low for each resident. Medicine Technicians will refill the medication cart utilizing the resident's overflow medication when they have 7 days' worth of medication left in the cart. Medicine Technicians also reported that once they pull the last overflow medication, a refill order is placed to prevent any missed doses. Record reviews of resident MAR sheets and Prescription orders revealed that resident medications are filled well in advance. Additionally, LPA observed that MARs allow Medicine Technicians a space to document reasons for missed medication if it occurs. Based on record reviews, the LPA did not observe any indications of missed medications due to not having the medications filled in a timely manner.

Continued...

SUPERVISORS NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Sulma Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2026

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20260618143811

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	FACILITY NUMBER: 342701213
	VISIT DATE: 09/17/2026

NARRATIVE

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Allegation: Staff are not ensuring medications are not left unattended.
It was alleged that staff are leaving medications unattended. LPA conducted a tour of the facility and did not observe any medication left unattended in any of the common areas or resident bedrooms. Based on interviews, it was learned that medications were stored in a locked medication room or on locked rolling medication carts. LPA also conducted a tour of the medication room. The medication room was locked and made inaccessible to residents and guests. Medication carts in the room were also observed to be locked. LPA observed that Medicine Technicians were able to access the locked areas and carts utilizing keys. Based on the information gathered, there is not sufficient evidence to indicate that staff are not ensuring medications are not left unattended.

Allegation: Staff are not ensuring that residents are taking their medications.
It was alleged that staff are not ensuring that residents are taking their medications. During LPA's tour of the facility, it was learned that Medicine Technicians administer medications following the times outlined by the doctor's orders. Interviews with Medicine Technicians indicated that medications are administered following the times outlined on the MAR. Record reviews of 5 out of 5 resident MARs indicated that they had taken their medications during the review period of 6/1/26 through 6/30/26. Based on the information gathered, there is not sufficient information to indicate that staff are not ensuring that residents are taking their medication.

Although the above allegations may have occurred or may be valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur. Therefore, the above allegations are unsubstantiated.
An exit interview was conducted, and a copy of this report was provided to the facility.

SUPERVISORS NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Sulma Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2026

LIC9099 (FAS) - (06/04)

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