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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002805
Report Date: 10/17/2023
Date Signed: 10/17/2023 12:27:37 PM


Document Has Been Signed on 10/17/2023 12:27 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:CARLTON SENIOR LIVING ORANGEVALEFACILITY NUMBER:
345002805
ADMINISTRATOR:AMANDA SMITH WOLTHUISFACILITY TYPE:
740
ADDRESS:8773 OAK RDTELEPHONE:
(916) 988-2200
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:136CENSUS: 78DATE:
10/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Administrator, Amanda Smith TIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Talwinder Bains arrived on 10/17/23 to conduct the annual inspection.
LPA met with Administrator, Amanda Smith who assisted LPA during today's inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed residents (4) and staff files (4). All residents (4) and Staff (4) files contained the required paperwork. Staff have current first aid and CPR training. Facility was clean. All required postings were observed.

LPA and Amanda toured the facility together to ensure the health and safety of residents in care. The areas toured included residents rooms, bathrooms, kitchen, common areas and outside area. The food supply is within compliance, 2 days of perishable and 7 days worth of non-perishable food items. All exits were unobstructed. The administrator's certificate is current. LPA checked the kitchen area for the ability to prepare and store food. Knives and Sharp objects found to be locked . LPA observed cleaning products and other toxins to be locked away. LPA observed the area used for medication to be locked and inaccessible to residents. LPA observed smoke detectors and carbon monoxide detector at the care home are operational. Fire extinguisher is ready for emergency use and was last serviced on 12/28/22. Water temperature is within compliance (109 degree F) .Inside temperature was observed to be 75 degree F. In the areas toured, there were no health or safety violations were observed.

No deficiencies were observed or cited during today's visit.
Exit interview conducted. A copy of this report was printed and given to Amanda.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2023
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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