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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347002787
Report Date: 11/10/2020
Date Signed: 11/10/2020 05:08:27 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/09/2020 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 27-AS-20200609134507
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: 127DATE:
11/10/2020
UNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Lisa Schumann, AdministratorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Facility did not provide adequate supervision which resulted in an unwitnessed fall and resident sustaining injury
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Michael Hood and Angela Hood contacted Administrator Lisa Schumann via telephone to deliver findings for a complaint investigation of violation of facility did not provide adequate supervision which resulted in an unwitnessed fall and in resident sustaining injury. This visit was conducted via telephone due to COVID-19 and precautionary measures.

During the course of the investigation, LPA conducted interviews with staff and reviewed documentation pertinent to the investigation. According to interviews with staff members S1, S2, and Director of Residential Services (DRS), staff were checking in on resident (R1) every 2 hours. Interviews with DRS, S2, and Administrator indicated that staff were notified that R1 was a fall risk and fall mats were placed beside R1’s bed to help prevent injury.

** Report continued on 9099-C **
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2020
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 2
Control Number 27-AS-20200609134507
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 SACRAMENTO
FACILITY NUMBER: 347002787
VISIT DATE: 11/10/2020
NARRATIVE
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The Resident Caregiver Notes indicated that Bristol Hospice provided a fall mat for R1 on 2/25/2020 and staff were instructed to conduct regular checks on R1 “approximately every two hours.”

Based on interviews conducted by LPA and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. No deficiencies are being cited during this visit.
Due to the COVID-19 outbreak, LPA is sending an electronic copy via email of this report to the Executive Director for signature and return to CCLD.

Exit interview conducted.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2020
LIC9099 (FAS) - (06/04)
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