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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003574
Report Date: 03/01/2021
Date Signed: 03/01/2021 02:24:14 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 SENIOR LIVING ORANGEVALEFACILITY NUMBER:
347003574
ADMINISTRATOR:LISA SCHUMANNFACILITY TYPE:
740
ADDRESS:8773 OAK AVETELEPHONE:
(916) 988-2200
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:136CENSUS: 39DATE:
03/01/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Lisa Schumann, Executive Director TIME COMPLETED:
01:05 PM
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Licensing Program Analyst (LPA) Wolter spoke with Executive Director (ED) Lisa Schumann by phone on 03/01/2021 due to COVID-19 and precautionary measures, LPA and ED discussed incident and/or reports that Community Care Licensing (CCL) received 02/18/2021 and 02/23/2021.

Incident report received 02/18/2021 stated R1 was sent to the hospital due to a cough, weakness, and history of pneumonia. R1 was admitted to the hospital, no discharge date was listed. LPA followed up with ED and learned that R1 passed while at the hospital, death report to be sent to CCL by close of business 03/01/2021.

Death report received on 02/23/2021 stated that R2 was on hospice and passed away at the facility, death report was missing immediate cause of death. ED and LPA discussed R2's diagnosis and ED stated she would send over further information regarding R2's hospice care plan.

At this time no deficiencies are being cited.
Exit interview conducted and a copy of report provided to ED by email, ED to return a signed copy to CCL either by email, fax, or USPS. A signed copy should also be retained for facility records.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle WolterTELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2021
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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