Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005464
Report Date: 05/03/2019
Date Signed: 05/03/2019 03:24:44 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 ELK GROVEFACILITY NUMBER:
347005464
ADMINISTRATOR:AMANDA SMITHFACILITY TYPE:
740
ADDRESS:6915 ELK GROVE BLVD.TELEPHONE:
(916) 714-2404
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:180CENSUS: 141DATE:
05/03/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Personal Care Manager (PCM), Cal MendiolaTIME COMPLETED:
03:45 PM
NARRATIVE
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LPA Laura Munoz conducted a case management visit to this facility today, 05/03/19 to follow up on an incident that occurred on 04/20/19. LPA met with Personal Care Manager, Cal Mendiola and spoke to Executive Director, Amanda Smith on the phone.

The facility self reported an incident on 04/26/19 that occurred on 04/20/19. On 04/20/19 at approximately 5:30pm, R1 eloped from the facility through the front of the building. According to the Executive Director, the facility had a live band playing for the residents. When the band was leaving the building, it appears R1 walked out with the band. Once the facility realized R1 had eloped, facility staff contacted local law enforcement who located R1 at 6:40pm approximately .25 miles from the facility. R1 was returned to the facility without incident.

Upon review of R1's current LIC602/physician's report dated 08/02/18, R1 has a diagnosis of Mild Cognitive Impairment. R1's LIC602/physician's report also states R1 cannot leave the building unassisted. Per Mr. Mendiola, this is the first incident of R1's eloping. LIC602/physician's report does not note any wandering behavior however does state R1 can be confused/disoriented.

After the incident, a Wanderguard was placed on R1 with 1 hour checks. On 04/25/19, R1 was moved to the memory care unit of the facility, which is a secure environment with delay egress exits. Based on the information obtained, although R1 did not have a diagnosis of Dementia, R1's LIC602/physician's report documents R1 cannot leave the building unassisted.

Deficiencies are cited today in accordance with California Code of Regulations, Title 22, Section 87464(f)(1) and listed on the attached LIC809-D.

Exit interview and copy of report and appeal rights provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Laura MunozTELEPHONE: (916) 709-6317
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2019
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 ELK GROVE
FACILITY NUMBER: 347005464
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/10/2019
Section Cited
CCR
87464(f)(1)
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87464(f)(1) Basic Services
Basic services shall at a minimum include:
Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).
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Personal Care Manager agrees to the following: R1 was moved to the memory care on 04/25/19. The facility conducted in-service training on 04/23-26/19 topic: Stop and Watch and 04/23-26/19 topic: wander and elopement guidelines. The facility shall obtain a new physician's report for R1 and submit to CCL by POC date, 05/10/19.
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This requirement is not met as evidence by: Based on SIR submitted to the department, R1 eloped from the facility on 04/20/19. R1's LIC 602/Physician Report indicates R1 cannot leave the facility unassisted. R1 returned safely to the facility without incident. This poses a potential Health and Safety risk to clients in care.
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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: Maribeth SentyTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Laura MunozTELEPHONE: (916) 709-6317
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2019
LIC809 (FAS) - (06/04)
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