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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002787
Report Date: 06/26/2020
Date Signed: 06/26/2020 12:45:53 PM

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 PLAZA OF SACRAMENTOFACILITY NUMBER:
347002787
ADMINISTRATOR:LISA SCHUMANNFACILITY TYPE:
740
ADDRESS:1075 FULTON AVENUETELEPHONE:
(916) 971-4800
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:185CENSUS: 140DATE:
06/26/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Manny Dirar Associate DirectorTIME COMPLETED:
12:55 PM
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Licensing Program Analysts (LPAs) Angela Hood and Michael Hood spoke with Associate Director Manny Dirar via telephone to conduct a case management visit. Today's visit was conducted by telephone due to COVID-19 and precautionary measures. The purpose of the visit is to follow-up on four incident reports that were received by the Department.

On 6/11/20, R1 was found on the floor near their bedside and was sent to the hospital. R1 is currently in skilled nursing for physical therapy.

On 6/14/20, R2 was noted to have low blood pressure and unresponsive. R2 was sent to hospital and has returned to facility with no new medication.

On 6/14/20, R3 was found experiencing pain in right side of body. It was noted that R3's legs were warm to the touch and red. R3 was sent to hospital and has returned with new medication orders for Urinary Tract Infection (UTI).

On 6/15/20, staff responded to pull cord for R4. R4 was found in bathroom and unable to stand from bathroom toilet. R4 was sent to hospital and has returned to facility with new medication order for UTI.

LPAs requested resident file documentation for all four residents. Facility will email documents to LPA Michael Hood for further review.

At this time, deficiencies are not being cited. A copy of this report has been emailed to the facility and the associate director was advised that a signed copy of the report shall be submitted to CCLD within 10 days of receipt of this report. Exit interview conducted.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 243-4743
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2020
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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