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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005464
Report Date: 03/02/2023
Date Signed: 03/02/2023 01:02:24 PM


Document Has Been Signed on 03/02/2023 01:02 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:CARLTON PLAZA OF ELK GROVEFACILITY NUMBER:
347005464
ADMINISTRATOR:JENNELL REVERAFACILITY TYPE:
740
ADDRESS:6915 ELK GROVE BLVD.TELEPHONE:
(916) 714-2404
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:180CENSUS: 123DATE:
03/02/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Executive Assistant Krystal CosainoTIME COMPLETED:
10:30 AM
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Licensing Program Analysts (LPAs) Vincent Moleski and Jason Lund arrived at Carlton Plaza for an unannounced case management visit on Thursday, March 2, 2023 in response to an unusual incident report for a resident (R1) who fell on February 3, 2023, suffering a fractured wrist. LPAs Moleski and Lund met with executive assistant Krystal Cosaino and explained the purpose of the visit. LPAs Moleski and Lund requested and reviewed the facility's LIC 500, R1's resident records, and R1's care plan.

LPAs requested to speak with R1, as well as S1 and S2, but were unable to do so. R1 is still in skilled nursing for her injury, and S1 and S2 were not working at the time of the visit.

LPAs Moleski and Lund requested an updated LIC 500 from the facility, and an updated care plan for R1.

No deficiencies were cited during this visit. An exit interview was held and a copy of the report was left with Cosaino.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2023
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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