<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347005464
Report Date: 05/16/2022
Date Signed: 05/16/2022 11:05:45 AM

Unsubstantiated


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
03/03/2022 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20220303081924
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: 122DATE:
05/16/2022
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Jennell ReveraTIME COMPLETED:
11:05 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility gave resident wrong medications
Non-skilled professional is administering insulin injections
Facility is not ensuring resident receives meals
Facility is short staffed
Facility is not providing services as identified in care plan
Facility disclosed information regarding resident to unauthorized person
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 5-16-22 at 9:20am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver findings for the complaint allegations noted above. LPA met with Administrator Jennell Revera and explained the purpose of the visit. During this investigation, LPA interviewed Administrator, Staff1 (S1), S2, and S3. LPA also interviewed Resident2 (R2) and R3. LPA also interviewed home health nurse, registry nurse, Ombudsman, and an attempted interview with additional outside party for Resident1 (R1). Records reviewed by LPA included medication log sheets for R1, physician orders for R1, service plan for R1, board of registered nursing verifications, care logs for R1, facility staffing schedule with actual hours worked for February, March, and April 2022, facility menu for March 2022, emergency contact information for R1, and physician’s report for R1. Additionally, LPA conducted a mealtime observation on 4-21-22.

Allegation #1: Facility gave resident wrong medications. LPA interviewed Administrator, S1, S2 and S3. LPA also reviewed physician orders for R1 as well as medication log sheets for R1 dated February and March of 2022. {Cont. on 9099C}
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2022
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 6
Control Number 27-AS-20220303081924
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 ELK GROVE
FACILITY NUMBER: 347005464
VISIT DATE: 05/16/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
 Based on interviews and records reviewed it was determined that R1 discharged from facility and medications have been removed from facility per regulations and facility protocol. Orders reviewed matched medication logs reviewed. Medication logs indicated that medications prescribed to R1 were given as ordered, and no additional medications given based on record reviews and interviews. As a result, there is not a preponderance of evidence to conclude if facility ever gave wrong medications to R1 based on documents reviewed and interviews conducted. Therefore, this allegation is UNSUBSTANTIATED.

Allegation #2: Non-skilled professional is administering insulin injections. Allegation stated a non-skilled professional administered insulin to R1. LPA interviewed Administrator, S1, S2, and S3. LPA also interviewed registered nurse from nursing registry and registered nurse from home health agency. Additionally, LPA reviewed medication log sheets for R1 dated January to March of 2022, Physician orders for R1 and board of registered nursing documents. Based on record reviews, it was revealed that currently licensed nurses administered insulin to R1 per physician orders as indicated by signature on medication log sheets. Based on interviews conducted, there was no observation of any non-skilled professionals administering insulin to R1. As a result, there is not a preponderance of evidence to conclude that a non-skilled professional ever administered insulin to R1, therefore this allegation is UNSUBSTANTIATED.

Allegation #3: Facility is not ensuring resident receives meals. LPA interviewed Administrator, S1, S2, and S3. LPA also conducted a mealtime observation on 4-21-22 and reviewed facility menu. Allegations states that R1 did not receive a meal at least 3 times. Based on interviews and record reviews it was determined that R1 was offered meals regularly and based on a modified menu for R1’s diabetic diet with occasional refusals; resulting in later than normal mealtimes. Based on observation by LPA it was determined that facility was appropriately staffed in the dining room and serving residents in care timely and according to the current menu. Observation by LPA also determined that special requests by residents were honored. Based on the interviews conducted, records reviewed and observation, there is not a preponderance of evidence to conclude that facility did not ensure meals for R1. As a result, this allegation is UNSUBSTANTIATED.

{Cont. on 9099C}

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 27-AS-20220303081924
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 ELK GROVE
FACILITY NUMBER: 347005464
VISIT DATE: 05/16/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Allegation #4: Facility is short staffed. LPA interviewed Administrator, S1, S2, and S3 as well as R2 and R3. LPA also reviewed facility assisted living staffing schedule for February and March of 2022, actual hours worked for February 2022, March 2022, and April of 2022, medication log sheets for R1 dated January through March of 2022, and care logs for R1 dated February to March of 2022. Based on interviews and record reviews it was determined that although staff call offs occurred during February and March 2022, there have been on-call staff and management available to fill shifts as necessary. Based on actual hours worked, it was revealed that staffing levels matched that of the facility schedule during February and March of 2022. Interviews with R2 and R3 revealed care needs are met, and no concerns with staffing levels at this time. A review of medication logs sheets and care logs for R1 revealed R1 received care and medications as prescribed. Interview with Administrator revealed staffing schedule is modified based on census and level of care for residents. Based on interviews and record reviews, there is not a preponderance of evidence to conclude facility operated consistently as short staffed, and unable to meet R1 and other resident needs as a result. Therefore, this allegation is UNSUBSTANTIATED.

Allegation #5: Facility is not providing service as identified on the care plan. Allegation noted assistance with Ted Hose for R1 was not completed. LPA interviewed Administrator, S1, S2, and S3. LPA also reviewed care log sheets for R1, and service plan for R1. Based on interviews and record reviews, it was revealed that R1 had specific needs addressed on service plan including Ted Hose Assistance from staff. Interviews conducted revealed care needs including Ted Hose Assistance were observed to be completed during February and March of 2022. Care logs reviewed covered the periods of February to March 2022 and indicated that service was completed by staff with some assistance provided by an outside party on various days and times. Based on interviews conducted and documentation of records reviewed, it is determined there is not a preponderance of evidence to conclude that R1 did not receive service as noted on the care plan, and this allegation is UNSUBSTANTIATED.

Allegation #6: Facility disclosed information regarding resident to unauthorized person. LPA interviewed Administrator, S1, S2, and S3, and reviewed emergency contact information for R1. LPA made attempted interviews with individual in question who allegedly received information regarding R1. Attempts were made on 4-25-22 and 4-26-22. Based on interviews conducted, it was stated that facility staff did not disclose inappropriate information to an unauthorized person and additionally, revealed that facility staff practice privacy precautions regarding release of information to parties not listed on authorized contact list for residents in care, including verification of listed names and permission obtained appropriately prior to release of information. {Cont. on 9099C}

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 27-AS-20220303081924
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 ELK GROVE
FACILITY NUMBER: 347005464
VISIT DATE: 05/16/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Based on the records reviewed and interviews conducted, there is not a preponderance of evidence to conclude facility staff released inappropriate information for R1 to an unauthorized person, therefore this allegation is UNSUBSTANTIATED.

No deficiencies cited. An exit interview was conducted with Jennell Revera and a copy of this report was left with Jennell Revera. Appeal rights provided.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
03/03/2022 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20220303081924

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: DATE:
05/16/2022
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Jennell ReveraTIME COMPLETED:
11:05 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is not providing diabetic diet to resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 5-16-22 at 9:20am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver findings for the complaint allegation noted above. LPA met with Administrator Jennell Revera and explained the purpose of the visit. During this investigation, LPA interviewed Administrator, Staff1 (S1), S2, and S3. Records reviewed by LPA include physician orders for R1, service plan for R1, and physician’s report for R1. Based on interviews conducted, it was revealed that during R1’s residency, R1 was provided a maple syrup product by staff which was not low or sugar free at least once during a meal. Records reviewed also revealed that this food item was not consistent with physician orders reviewed and facility menu indicating a diabetic diet for R1 to be provided. Physician’s report and service plan for R1 stated a diabetic diet for R1. Based on interviews and records reviewed, it is determined that the preponderance of evidence standard is met, therefore, this allegation is SUBSTANTIATED.

Citations are issued today under Title 22, Division 6, Chapter 8. An exit interview was conducted with Jennell Revera and a copy of this report was given to Jennell. Appeal rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 27-AS-20220303081924
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 ELK GROVE
FACILITY NUMBER: 347005464
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/26/2022
Section Cited
CCR
87628(b)(4)
1
2
3
4
5
6
7
87628(b)(4) Diabetes. (b)In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (4) Providing modified diets as prescribed by a resident's physician as specified in Section 87555(b)(7). This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee will read regulation 87628 and submit a signed declaration of understanding to LPA by POC due date.
Licensee will submit a plan which ensures residents with modified diets are receiving such diets as appropriate. Plan to be submitted to LPA by POC due date.
8
9
10
11
12
13
14
Based on interview, R1 was provided a maple syrup product by staff which was not low or sugar free and inconsistent with R1’s modified diet physician's order. This poses a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6