342701213-9-6-2023-27-AS-RWAE-CVERSP-20230906131704

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342701213
Report Date: 09/06/2023
Date Signed: 09/06/2023 01:17:08 PM

Document Has Been Signed on 09/06/2023 01:17 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		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:	09/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Kasie Wimmer - Administrator		TIME COMPLETED:	01:30 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	Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced required 1 year annual inspection visit. LPA met with administrator and explained purpose of visit. Hospice waiver to accept and retain up to 20 residents. Eight residents are receiving services through home health at this time. LPA and administrator evaluated the physical plant to ensure the health and safety of the clients in care. Areas inspected are including but not limited to the kitchen, resident bathrooms, living and dining room and outdoor areas. A tour of the resident rooms was conducted for the first and second floor of this facility. LPA observed the facility to be free of odor, clean and in good repair. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility. Laundry areas were toured. Residents, who were deemed able to do so 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 the needs of the residents at this time. A monthly calendar was observed to be posted as well. 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. Exterior courtyard for this memory care unit was properly fenced with delayed egress at the gate. Continue on 809-C Page 2

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth Wallace	TELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023

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	FACILITY NUMBER: 342701213
	VISIT DATE: 09/06/2023

NARRATIVE

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Continued from 809 - Page 2

LPA measured the water temperature, temperature measured at 110.7 degrees F which meets the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers were last inspected on January 1, 2023 and smoke and carbon monoxide detectors are in compliance with fire safety. First aid kit was checked and is complete.

LPA observed centrally stored medications, toxins, and sharp knives kept locked and inaccessible to clients. 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.

LPA received the following documents for facility file on today's date: LIC 308 Designation of Facility Responsibility and copy of Liability Insurance.

LPA reviewed six staff and five resident files. Resident emergency contact complete. LPA observed all staff and resident files complete. All staff have criminal record clearance and are associated to the facility.

Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection.

An exit interview was conducted with Administrator. A copy of this report and LIC 811 (Confidential Names) was left at the facility.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth Wallace	TELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023

LIC809 (FAS) - (06/04)

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