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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701213
Report Date: 05/22/2025
Date Signed: 05/22/2025 03:50:37 PM

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
10/15/2024 and conducted by Evaluator Kimberly Viarella
COMPLAINT CONTROL NUMBER: 27-AS-20241015143137
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: 142DATE:
05/22/2025
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Cal MendiolaTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff are not meeting resident's care needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility on 05/22/25 to continue this investigation into the above allegation. LPA identified herself upon arrival, stated the purpose of the visit, and asked to meet with the Designated Facility Administrator/Executive Director (ED). LPA met with Cal Mendiola and a brief interview followed.

Based on a review of records combined with information gathered from interviews, R1 was not receiving their necessary incontinent care. An entry made on 08/18/24 stated that R1 was not changed prior to the PM shift coming on duty and R1 and their bed “was soaking wet.” On 8/28/24, it was also noted that R1 had a large bowel movement and that R1 was not changed prior to the PM shift coming on duty. Additional care notes entered in the ALIS computer system, also described the following on 08/11/24 by 3 care partners. At 6:02, S3 wrote, “Care partners were not able to do last rounds because resident was unable to stand. Care partners decided to wait until AM were here to try and stand R1 up to try again.” LPA asked S3 to describe how they cleaned and changed R1. S3 stated that because of R1's body type/shape, that it now required,
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025
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 4
Control Number 27-AS-20241015143137
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: 05/22/2025
NARRATIVE
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 "at least 2 people to hold R1 up and steady, otherwise R1 sways back and forth. R1 has slid down onto the floor before because we can't keep R1 steady - their legs are weak." The third person is the one who actually cleans and changes R1. LPA asked why they didn't change R1 when R1 was horizontal in bed. S3 responded that they have tried that but, “R1 is very heavy and difficult to move, especially when R1 is sound asleep. R1 is dead weight then, and some of the care partners are more petite than others. With an average person, that might not be an issue but R1 is big and heavy.”

LPA observed care notes in logs which state, at 12:35 AM, during the NOC shift, , “We were not able to stand the resident up with 3 care partners. The resident was deadweight and was not assisting. Resident was very weak and was not understanding instructions. We contacted the med tech for advice. Alpha One assisted with continent care. Resident is becoming too heavy to turn and stand. The last observation made regarding weight/condition was in July. We have not received any updates regarding this issue. 

This issue continued as documented by another care partner on 08/13/24 when they logged, “The resident was hard to do continent care and we call help from assisted living. We checked R1 4 care partners at the bed.” LPA observed that an updated service plan was added to ALIS for R1 on 08/15/24. LPA noted the following upon reviewing the care plan dated 08/07/24. LPA observed from a review of records that from December of 2023, to October of 2024, R1 gained 18 pounds.

LPA reviewed documents including discharge paperwork from Kaiser. R1 had a rash and swelling in their groin area and they were diagnosed with a urinary tract infection.

On page 2 the new plan stated that the, “resident’s risk for falling will be noted by staff.”  It went on to state, "the resident is encouraged to be out in the common areas during waking hours. Resident is encouraged to sit or lay down when feeling or staff sees resident fatigued.  Resident wears proper footwear when awake and walking (tennis shoes) resident is on toileting services. Staff are to check on resident approximately every 2 hours for toileting assistance. Staff are to redirect resident back to the common areas, if and when, available.”  LPA requested incident reports for R1. From 07/06/24 to 09/01/24, R1 had 1 witnessed and 4 unwitnessed falls. 

R1 was not getting their incontinent care needs met. R1's care plan should have been updated after the first fall to include a strategic fall prevention plan in order to prevent the following falls from occurring.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20241015143137
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: 05/22/2025
NARRATIVE
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The standard for the preponderance of evidence has been met and the Department finds the allegation, "Staff are not meeting residents care needs." to be SUBSTANTIATED. According to the California Code of Regulations, Title 22, this deficiency was cited on the LIC9099 D page.

A copy of this report was provided along with appeal rights and an exit interview was conducted.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Citations on this Visit Report are Under Appeal!

Control Number 27-AS-20241015143137
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: 05/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
05/23/2025
Section Cited
CCR
87625(b)(3)
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87625 Managed Incontinence
(b) In addition to Section 87611...the licensee shall be responsible for..:3) Ensuring that incontinent residents are kept clean and dry ... The Licensee did not ensure that the above regulation was enforced as evidenced by:
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The Designee stated that since this complaint orignated, a hoyer lift was added to assist with this resident. Currently the resident utilizes a catheter. R1 will have increased monitoring by the nursing staff and all staff witll have addtional training on
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Based on a review of records, as well as interviews with staff carestaff documented at least 3 incidents when R1 was not changed or could not be changed. This posed(es) an immediate threat to the health safety and personal rights of residents in care.
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incontinent care skin checks and documentation. A plan for training will be submitted to CCL by the close of business 05/23/25 with an outlne and dates for completiong.
Under Appeal
Type A
05/23/2025
Section Cited
CCR
87463(g)
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87463 Reappraisals (g) The licensee shall ensure corresponding changes are made in the care and supervision provided to the resident.
The licensee did not ensure the above regulation was met as evidenced by:


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Designee stated that the Director of Memory Care will update the Care Plan to include a strategic fall prevention plan, a plan for skin breakdown prevention, and any other concerns that have developed since this complaint was initiated. A draft of this plan will be completed and
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Based on a records review, R1 had a total of 5 reported falls. Updated appraisals did not show changes to care and supervision. No strategic fall prevention plan was put into place. This posed(es) an immediate threat to the health safety and personal rights of residents in care.
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submitted by the close of business 5/23/25.
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: 05/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4