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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701213
Report Date: 01/23/2025
Date Signed: 01/28/2025 10:07:10 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
06/24/2024 and conducted by Evaluator Kimberly Viarella
COMPLAINT CONTROL NUMBER: 27-AS-20240624162127
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: DATE:
01/23/2025
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Kasie WimmerTIME COMPLETED:
06:10 PM
ALLEGATION(S):
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Personal Rights
INVESTIGATION FINDINGS:
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On 1/23/25, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver the findings of this complaint investigation. The LPA identified herself upon arrival, stated the purpose of the visit, and asked to meet with the Designated Facility Administrator. LPA met with Kasie Wimmer and a brief interview followed.

A resident (R1) sustained a fall on 5/28/24 in the common area of the facility while trying to transfer independently from a chair into their wheelchair. R1 was taken to Kaiser Permanente. R1 had a CT scan which showed no acute hemorrhage or calvarial fracture and no mass effect of herniation. Tylenol was given for pain. Discharge paperwork listed to monitor R1 and if symptoms got worse, to bring R1 back to the hospital. R1 returned to the facility.

On 5/29/24, R1 entered a different resident's room and sustained a fall at approximately 1303 hours. R1 remained on the floor in a pool of blood until facility staff entered the room at approximately 1315 hours.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025
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 6
Control Number 27-AS-20240624162127
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: 01/23/2025
NARRATIVE
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R1 was found after staff received a phone call from SafelyYou, a service that detected that a resident had fallen in that room. R1 was taken to UC Davis Medical Center. R1 was noted to have a large hematoma to the right side of their forehead. R1 sustained multiple head bleeds including "significant worsening" of an old intracranial hemorrhage.

On 5/30/24, R1 passed away. R1's cause of death was listed as Intraparenchymal Hemorrhage due to a ground level fall.

Facility staff, S3, stated that they were assigned to R1 on 5/29/24. S3 saw R1 in the common area of the facility before S3 went on break. All other facility staff interviewed stated that they were either taking care of another resident, or they were not in the common area at the time of the incident. The facility was unable to provide a staff schedule indicating which staff were present in the common area.

This LPA reviewed the Personal Care Interview conducted on 3/28/19. On page 3 it stated that R1 “needed minor help transferring” and on page 4 a check mark indicated that R1 was a FALL RISK.

In the notes from a care conference on 3/25/20, Staff checked off that there were concerns for R1: balance/gait, FALL RISK, and concerns were also raised about wandering and exit seeking behaviors. On page 3 it stated that R1 had a history of falls and on page 4 it stated that R1 had fallen twice in the past year. On page 5 of this report, when asked if R1 had a history of wandering and exit seeking, “yes” was checked.

Individual Service Plans indicated that R1 was a fall risk and that R1's wandering would be addressed accordingly. However, the plan did not list any specific strategy to mitigate R1's fall risk and wandering behavior. The Individual Service Plan was not updated after R1's fall in April of 2024 or after R1's fall on 5/28/24. It was updated on 5/30/24 after R1's fall on 5/29/24.

The LPA observed the following upon reviewing the R1's re-assessment dated 5/30/24. On page 2 number 6, it was noted that R1 was a FALL RISK. On page 3, section 2, number 1, under "Functional Capabilities, Ambulation, and Transfers," the fact that R1 was a fall risk was not mentioned. There were two boxes checked off. One indicated that R1 used a walker independently and was able to get in and out unassisted. The second box indicated that R1 was not able to walk and that R1 used a wheelchair. In the notes section it stated, "NON-AMBULATORY: Resident ambulates herself utilizing their wheelchair and has a walker that
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 27-AS-20240624162127
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: 01/23/2025
NARRATIVE
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they can use to assist with transfers." Under section 2 it asked "Does the resident have any of these functional capability concerns?" Balance/Gait was checked but there were no notes provided or strategies listed under the notes section to address the concern. On page 6 question 6 asked, "Does the resident request or require ESCORT assistance to the dining room, activities, or anywhere (destinations) within community?" "Yes" was checked off to indicate that R1 needed assistance going to and returning from the dining room. Question 12 asked if R1 had fallen two of more times in the past year. "No" was checked off, which was incorrect; R1 had a documented fall on 4/21/24, another on 5/28/24 and the final fall on 5/29/24 which resulted in R1's death. R1 was sent out for evaluation for the first fall which resulted in a radius fracture. R1 was sent out for evaluation for the second fall as well. Because question 12 was answered incorrectly, the follow up questions were not answered. On page 7, as part of a fall risk assessment, staff were supposed to check off the appropriate box. Staff checked off that R1 had 1 fall within the last 3 months instead of the box that indicated R1 had 2 falls within the past 12 months. Page 9 also indicated that R1 had a history of exit seeking, a habit that, combined with being a fall risk would require increased checks.

Upon reviewing the Individual Service Plan, this LPA observed that on pages 2 and 3, the plan indicated that R1 would receive round trip escorts by staff daily to R1's desired locations. The plan also stated that R1's "risk for falling would be noted by staff" and that staff were supposed to "note any changes in condition, balance problems or weakness, to supervisor." After the fall on 5/29/24, R1's care plan did not increase the frequency of checks on R1.



Staff interviews revealed that the amount of time between resident checks varied amongst staff. S1 stated in an interview that when a resident returns from the hospital, they were put on alert charting and they were checked on every hour for 3 days. S1 went on to say that if a resident were a fall risk, they would be checked on every 10 - 15 minutes. S1 also added that most of the residents were in the common area and were "constantly" being checked on. S1 stated that R1 got the "standard" number of checks and did not require any additional checks or care.

S2 stated that residents are checked on every 2 hours but if they have returned from the hospital, they were put on alert charting and checked every hour. S2 went on to say that R1 was checked on every 2 hours. Later during the same interview, S2 stated that R1 was on alert charting and being checked on every hour.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 27-AS-20240624162127
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: 01/23/2025
NARRATIVE
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S3 stated that residents were checked every 2 hours and that these checks were documented in the computerized system called ALIS. S3 stated that R1 required assistance with all levels of daily living activities. R1 utilized a wheelchair but would always try to stand up and get out of the chair on their own. Due to this, R1 was a fall risk.

On 5/28/24 while the caregiver who was typically assigned to take care of R1 was on break, R1 attempted to get up on their own. R1 was in the common area and whoever is in the common area is responsible to supervise the residents. S2 stated that they did not know who was in the common area at that time, but R1 attempted to get up and they fell. R1 was sent out for evaluation at the hospital and returned the same day. It remains unknown as to who was supervising the residents in the common area that day. Those interviewed said that whoever was stationed there was responsible for supervising the residents.

S5 stated that on 5/28/24, facility staff were having a team meeting, but that a staff person was in the common area watching the residents. S5 could not remember who was in the common area at the time. R1 attempted to transfer to a chair independently, fell, and hit their head. S5 also stated that it was common for residents to want to sit in a normal chair while eating in the common area. According to S5, facility staff were in the kitchen and the switch between shifts was taking place. Facility staff turned their head and when they looked back, R1 was falling. R1 was sent to the hospital and returned the same day.

S6 stated that they were made aware of R1’s first fall on 5/28/24 by the Memory Care Director. The two reviewed video footage and saw R1 attempt to transfer from a chair back to their wheelchair. S2 saw R1 stand up, lose their balance, and fall. S6 said that facility staff were on their way to R1 when R1 stood up, but by the time they got there, R1 was on the floor.

S1 stated that they did not know how no one saw R1 use their wheelchair to enter another resident’s room on 5/29/24. S1 stated they did not know who was watching the common area at the time. S1 added that it should be a team effort for who was watching the residents in the common area. S1 did not know who found R1 on the floor. S1 “definitely” believed that R1 should have had better supervision on 5/29/24.

S4 stated that residents were checked on every two hours and that the residents mostly stayed in the common areas where they could be supervised by staff. S4 stated that R1 had a total of 5 falls at the facility and that R1 did not receive any extra supervision because the family would not pay for it. When asked who
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 27-AS-20240624162127
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: 01/23/2025
NARRATIVE
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was watching R1 when they fell on 5/28/24, S4 stated, "all of us." On 5/29/24, S4 stated that they think R1 fell when staff were getting lunch ready. They had an issue with another resident that pulled some staff away. S4 thought the fall could have been prevented, "If the staff saw R1 go into a different resident's room, they would have went in there and taken R1 out." When asked if they thought that the facility was understaffed, S4 said yes. "If there had been more people working, then there would have been more people watching the common area". S5 did not feel the facility was understaffed and believed that the residents were checked on every hour. S5 stated that if a resident were determined to be a fall risk, then they were checked on every thirty minutes. S5 was asked if R1 was supposed to be watched more closely since they just fell and went to the hospital the day before. S5 said "yes", R1 should have been on high watch. "It's not a policy, just common practice with them to watch them 24/7 after coming back from the hospital."
S7 reported that R1 liked to wander after lunch. "It was like clockwork," S7 said, " R1 would wheel themselves around after lunch." S7 said that R1 was allowed to wander between their room and the common area. The records reviewed showed that as far back as 3/28/19, there were documented concerns regarding R1 being a fall risk. The report from 3/25/20 stated that R1 had 2 falls within the past year. The records reviewed showed that a comprehensive, strategic plan was not developed or communicated to the staff caring for R1. The functional assessment conducted had unanswered and incorrect answers included, which in turn, were used to calculate R1's fall risk. The staff did not understand how often to check on R1 as evidenced by the varying answers of those interviewed. The care plan indicated that the resident was to be redirected if they attempted to stand by themselves. In order for that strategy to be effective in preventing a fall, the staff person needed to be close enough to communicate with the resident and able to intervene if R1 ignored the redirection. The facility did not supervise R1 which led to R1 wandering into another resident's room, standing, falling, and sustaining a serious head injury, which resulted in R1’s death.
Under Basic Services, California Code of Regulations 87464(d), “a facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident’s needs…” The standard for the preponderance of evidence has been met and the department finds the above allegation SUBSTANTIATED. This deficiency is included on the LIC 9099D page. This report has been amended on 1/28/25 to include the following: A civil penalty in the amount of $500 is hereby assessed due to a violation resulting in injury to a resident, as described above and is cited on the LIC 421IM page. Additional civil penalties are currently being evaluated by the Department, pursuant to Health and Safety Code § 1569.49(f). An exit interview was held with Wimmer. Appeal rights, a copy of the civil penalty assessment, and a copy of this amended report were left with Wimmer.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 27-AS-20240624162127
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/24/2025
Section Cited
CCR
87464(d)
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Basic Services CCR 8764(d)
(d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs.... The licensee did not ensure these needs were met as evidenced by:

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The Administrator stated that following this event a new protocol was enacted where floor time to cover the common area is scheduled into all carestaff assignments for the day thus eliminating ambiguity and confusion. The Administrator will provide an example of one of these schedules to
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Based on a records review and information gathered from interviews, it was documented that R1 was a fall risk as far back as 3/28/29. A plan to mitigate these falls was not put into place.This posed an immediate threat to the health, safety and/or personal rights to residents in care.
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Community Care Licensing by the close of business 1/25/25.
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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.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6