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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347005464
Report Date: 10/10/2023
Date Signed: 10/10/2023 02:58:49 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
08/23/2023 and conducted by Evaluator Vincent Moleski
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230823160535
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: 128DATE:
10/10/2023
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Andrea QuintanillaTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Due to lack of staffing, staff do not answer resident call buttons timely
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with director of resident services Andrea Quintanilla and explained the purpose of the visit.

This investigation consisted of record review and interviews with staff and residents.

During an interview, Jennell Revera said staff are expected to respond to pendant calls within 15 minutes. Revera said staff hours were recently reduced.

LPA Moleski reviewed 30 days of call button responses for a resident (R1), dated from July 30, 2023 to August 29, 2023.

[continued on 9099-C]
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023
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 6
Control Number 27-AS-20230823160535
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: 10/10/2023
NARRATIVE
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During these 30 days, 46 call responses were over 15 minutes out of a total of 155 calls. Of these, 30 were over 20 minutes. Of these, 10 were over 30 minutes. Of these, four were over 40 minutes. On August 24, 2023, a call from R1 at 7:23 p.m. took one hour and 29 seconds to clear. On August 7, 2023, a call from R1 at 9:08 p.m. took 57 minutes and 27 seconds to clear. On August 7, 2023, a call from R1 at 10:33 a.m. took one hour, 18 minutes and 14 seconds to clear.

LPA Moleski reviewed 30 days of call button responses for a resident (R2), dated from August 20, 2023 to September 19, 2023. During these 30 days, 15 call responses were over 15 minutes out of a total of 35 calls. Of these, 10 were over 20 minutes. Of these, four were over 30 minutes. Of these, two were over 40 minutes. A call from R2 on August 20, 2023 at 6:19 a.m. took 57 minutes and 10 seconds to clear.

LPA Moleski reviewed 30 days of call button responses for a resident (R4), dated from August 20, 2023, to September 17, 2023. During these 30 days, 43 responses were over 15 minutes out of 147 total. Of these, 26 were over 20 minutes. Of these, 15 were over 30 minutes. Of these, five were over 40 minutes. A call from R4 on August 31, 2023 at 6:44 p.m. took one hour, 10 minutes and 51 seconds to clear. A call from R4 on August 29, 2023 at 6:58 p.m. took 51 minutes and 12 seconds to clear. A call from R4 on August 28, 2023 at 5:31 p.m. took one hour, 33 minutes and 51 seconds to clear. A call from R4 on August 24, 2023 at 6:36 p.m. took one hour, 38 minutes and 58 seconds to clear.

LPA Moleski reviewed 30 days of call button responses for a resident (R6), dated from August 20, 2023 to September 18, 2023. During these 30 days, six responses were over 15 minutes out of a total of 19 calls. Of these, five were over 20 minutes. Of these, two were over 30 minutes.

LPA Moleski reviewed 30 days of call button responses for a resident (R7), dated from August 20, 2023 to September 19, 2023. During these 30 days, 10 responses were over 15 minutes out of a total of 28 calls. Of these, seven were over 20 minutes. Of these, four were over 30 minutes. Of these, two were over 40 minutes. A call from R7 on August 23, 2023 at 7:20 a.m. took 54 minutes and zero seconds to clear.

[continued on 9099-C]
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 27-AS-20230823160535
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: 10/10/2023
NARRATIVE
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LPA Moleski interviewed 13 staff members (S1-S13). Of these, nine staff members (S3, S4, S5, S7, S8, S9, S10, S11, and S12) said the facility was understaffed, and that pendant calls were not being cleared in a timely manner as a result.

LPA Moleski interviewed seven residents (R1-R7). Of these, four residents (R2, R3, R4, and R7) said the facility was understaffed and voiced concerns regarding call response times.

The department has determined the following as it relates to the allegation that, due to lack of staffing, staff do not answer resident call buttons timely:

Based on interviews with staff and residents, and based on record review, 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 87411(a). An exit interview was held with Quintanilla. Appeal rights and a copy of this report were left with Quintanilla.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 27-AS-20230823160535
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: 10/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/20/2023
Section Cited
CCR
87411(a)
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Personnel Requirements: "Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services."

This requirement was not met as evidenced by:
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Licensee agrees to conduct a staff training regarding call response procedures. Licensee agrees to submit a plan to address staffing needs. Licensee agrees to email LPA Moleski a copy of the staff training sign-in sheet and the above mentioned written plan.
vincent.moleski@dss.ca.gov
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Based on record review and interviews, there are not a sufficient number of staff at this facility to answer resident calls in a timely manner, which poses a potential health and safety risk.
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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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023
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
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
08/23/2023 and conducted by Evaluator Vincent Moleski
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230823160535

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: 128DATE:
10/10/2023
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Andrea QuintanillaTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff are not following infectious disease protocols
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with director of resident services Andrea Quintanilla and explained the purpose of the visit.

This investigation consisted of observations and interviews.

LPA Moleski observed a portion of dining room service on 8/29/23 and 9/12/23. LPA Moleski observed staff taking all necessary infection control measures during these occasions.

LPA Moleski interviewed five dining service staff members (S14-S18). All five dining service staff members described proper infection control procedures.

[continued 9099-C]
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023
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-20230823160535
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: 10/10/2023
NARRATIVE
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LPA Moleski interviewed seven residents (R1-R7). None of these seven residents voiced any concerns regarding dining service staff members’ infection control procedures.

LPA Moleski interviewed a Sacramento County public health nurse. The nurse said this facility did not need to inform a resident (R1) of a staff member (S19) falling ill with COVID-19, as it did not meet close contact criteria.

The department has determined the following as it relates to the allegation that staff are not following infectious disease protocols:

Based on observation and interviews, the above allegation is UNSUBSTANTIATED, which means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

An exit interview was conducted and a copy of this report was left with Quintanilla.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6