347005464-4-19-2023-27-AS-KHOS-CR8HT2-20230425062801

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347005464
Report Date: 04/19/2023
Date Signed: 04/19/2023 01:46:08 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 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
01/26/2023 and conducted by Evaluator Vincent Moleski

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20230126184225

FACILITY NAME:	CARLTON PLAZA OF ELK GROVE		FACILITY NUMBER:	347005464
ADMINISTRATOR:	JENNELL REVERA		FACILITY TYPE:	740
ADDRESS:	6915 ELK GROVE BLVD.		TELEPHONE:	(916) 714-2404
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95758
CAPACITY:	180	CENSUS:	DATE:	04/19/2023
		UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Jennell Revera		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Facility is not following infection control procedures

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Vincent Moleski and Jason Lund arrived unannounced to deliver findings on this complaint investigation. LPAs Moleski and Lund met with administrator Jennell Revera and explained the purpose of the visit.

This complaint was investigated by LPAs Moleski and Lund. The investigation consisted of nine staff interviews (S1-S9), ten resident interviews, interviews with administrator Revera, record review of facility infection control procedures, record review of Carlton Senior Living policy regarding infection control, and record review of PPE invoices.

Interviews with S1-S8 indicated that assisted living staff experienced a shortage of gowns during a one-to-two-day period during the recent outbreak of COVID-19. S9 worked in memory care and was not aware of the shortage in assisted living. [Continued on 812-C]

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent Moleski	TELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2023

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 3

Control Number 27-AS-20230126184225

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 GROVE	FACILITY NUMBER: 347005464
	VISIT DATE: 04/19/2023

NARRATIVE

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S1 indicated there was a PPE shortage. S2 was not working during this period but heard from coworkers that there was a PPE shortage. S3 said staff members were instructed to reuse gowns, but S3 used trash bags rather than reuse gowns. S5 and S6 said staff members were instructed to reuse gowns, but S5 and S6 went without gowns rather than reuse gowns. S4, S7, and S8 said they reused gowns.

In interviews, administrator Revera said staff used disposable gowns more than once during this shortage, as follows: According to Revera, staff donned gowns to care for a COVID-positive resident, hung up the gown inside the resident’s room, left to take care of other tasks, then returned to the same room and used the same gown to care for the same COVID-positive resident. Revera said this took place during a three-to-four-hour period while she was out acquiring more gown supplies.

The department has determined the following as it relates to the allegation that the facility is not following infection control procedures:

Based on interviews with administrator Revera and with S3-S8, facility staff did not dispose of gowns as required during the recent COVID-19 outbreak. Therefore, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met. This facility is being cited per 22 CCR Section 87470(b)(2)(B).

An exit interview was held with Revera. A copy of this report and appeal rights were left with Revera.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent Moleski	TELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 27-AS-20230126184225

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 GROVE	FACILITY NUMBER: 347005464
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/19/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/20/2023 Section Cited CCR 87470(b)(2)(B)	1 2 3 4 5 6 7	“PPE shall be removed and discarded in the nearest appropriate waste receptacle with a tight-fitting cover immediately upon completing a task.” This was not met based on LPA interviews with staff members.	1 2 3 4 5 6 7	Administrator will conduct staff training on proper disposal of PPE.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent Moleski	TELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2023

LIC9099 (FAS) - (06/04)

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