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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002805
Report Date: 07/31/2024
Date Signed: 07/31/2024 02:05:52 PM


Document Has Been Signed on 07/31/2024 02:05 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:MIRIAM FARISFACILITY TYPE:
740
ADDRESS:8773 OAK RDTELEPHONE:
(916) 988-2200
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:136CENSUS: 90DATE:
07/31/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Executive Assistant, Ellaina CanadyTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 07/31/2024 to conduct a case management visit and met with Executive Assistant, Ellaina Canady and explained the purpose of the visit.

The facility submitted a completed Unusual Incident/Injury Report (LIC624) on/around 07/22/24 regarding 1 missing bottle out of 3 bottles of Oxycodone (narcotic) for resident, R1 (hospice care) during pm med count on 07/20/24. IR stated that, on 7/20/24 Med Manager notified ED that during PM narcotic count a bottle of oxycodone was missing for R1, Prior to 2pm count on 07/20/24, R1 had 3 bottles of oxycodone. Sacramento County Sheriff’s Department was notified on 07/22/24 regarding this incident. Facility also notified CCLD, R1s physician, responsible party, hospice agency and other agencies as required. Facility launched their internal investigation and did the through search for this missing medication.

During today's visit LPA interviewed 2 staff members and requested documents related to incident which facility will send to LPA via email by 08/02/24.

This case is under review and Department will follow up as warranted.
No deficiencies were cited during today's visit.
Exit interview conducted and copy of the report left at the facility.




SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 07/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2024
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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