347005464-5-9-2024-27-AS-SRIN-D5S2ZN-20240530175038

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347005464
Report Date: 05/09/2024
Date Signed: 05/09/2024 09:53:52 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/01/2024 and conducted by Evaluator Vincent Moleski

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20240501152638

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: 137	DATE:	05/09/2024
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Jennell Revera		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Facility staff did not safeguard residents belongings

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 observation, interviews, and record review. LPA Moleski interviewed facility administrator Jennell Revera, two staff members (S1-S2), and a former resident’s responsible party (R1’s RP).

LPA Moleski reviewed a death report for a resident (R1) dated 4/17/24. The death report states that R1’s RP notified the facility on 4/7/24 that two of R1’s rings were missing. Staff searched various areas for the missing rings, but were unable to locate the rings, according to the death report. Local law enforcement was notified and a report number was provided. LPA Moleski reviewed an incident report dated 4/25/24, stating that R1’s RP notified staff that three of R1’s rings were missing. [continued on 9099-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: 05/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20240501152638

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CARLTON PLAZA OF ELK GROVE	FACILITY NUMBER: 347005464
	VISIT DATE: 05/09/2024

NARRATIVE

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LPA Moleski reviewed a police report dated 4/22/24. In this report, officers wrote that their case was closed “pending further investigative leads.”

Per 22 CCR Section 87218, “the licensee shall be presumed to have made reasonable efforts to safeguard resident property if there is clear and convincing evidence of efforts to meet each requirement specified in [HSC] Section 1569.153.” LPA Moleski took the following actions to determine whether this facility had made efforts to meet each requirement of that section:

LPA Moleski observed that the facility’s theft and loss policy is posted near the main entrance to the facility. LPA Moleski toured R1’s former apartment. The doors to the room cannot lock, and R1 had a roommate. LPA Moleski observed locking cabinets available for the storage of personal property. According to Revera, all caregivers have access to these cabinets. In an interview, R1’s RP said they had not requested any other secured, locked storage space for valuables.

LPA Moleski reviewed R1’s file. R1 was diagnosed with dementia and lived in the facility’s memory care unit. LPA Moleski observed information regarding the facility’s theft and loss prevention program present in R1’s admission agreement and in the resident handbook provided to new residents. However, the contents of HSC Sections 1569.152 through 1569.154 were not present in the materials provided to R1 and/or R1’s RP, as required per HSC 1569.153(k). The resident handbook states that employees are provided these sections.

LPA Moleski observed that R1 and/or R1’s RP declined to establish an inventory of personal property upon admission. HSC Section 1569.153(d) states that “The facility shall not be liable for items which have not been requested to be included in the inventory.” In an interview, R1’s RP said they did not recall having established an inventory of property for R1. This facility’s declination form clearly indicates that the facility is not liable for items not included in the inventory.

LPA Moleski requested records of semiannual reviews of theft and loss procedures and policies, pursuant to HSC Section 1569.153(g). Records were not available as semiannual reviews have not been conducted, according to Revera.

[continued 9099-C]

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent Moleski	TELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20240501152638

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CARLTON PLAZA OF ELK GROVE	FACILITY NUMBER: 347005464
	VISIT DATE: 05/09/2024

NARRATIVE

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LPA Moleski reviewed this facility’s written theft and loss policy. The policy states that the facility shall “document loss of personal property within 72 hours of the discovery of the loss or theft” and that “documentation will be made and maintained on Licensing Form #9060.” In an interview, Revera said these forms were not used to document the missing items as described above. The facility’s existing documentation regarding the missing rings does not contain estimated values for the items, as required per HSC Section 1569.153(c)(2), despite estimates of the missing rings having been given to police on 4/22/24.

Additionally, R1’s RP told LPA Moleski that a chair owned by R1’s family was not present in R1’s room upon R1’s death. LPA Moleski interviewed the facility’s memory care director (S1), who was aware that the chair had been reported missing. S1 did not know the location of the chair, and said that it may have been moved out of the room at some point to prevent falls. A report of this missing chair was not included in any of the incident reports received by LPA Moleski, and no report was made on an LIC 9060 form as specified in this facility’s theft and loss policy.

Based on the above findings, this facility shall not be liable for repayment or replacement of the missing items, as they were not entered into an inventory of personal property. However, the facility has not implemented several required elements of its theft and loss program: The facility did not document the missing items described above as stipulated in its theft and loss policy, did not include estimated values of the rings, did not document the missing chair, did not conduct semiannual reviews of theft and loss procedures and policies, and did not provide R1 and/or R1’s RP with HSC Sections 1569.152 through 1569.154 upon admission. Therefore, based on interviews, observation, and record review, the above allegation is SUBSTANTIATED, which means that the preponderance of evidence standard has been met.

This facility is hereby cited per HSC Section 1569.153. An exit interview was held with Revera. Appeal rights and a copy of this report were left with Quintanilla.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent Moleski	TELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20240501152638

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CARLTON PLAZA OF ELK GROVE	FACILITY NUMBER: 347005464
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/09/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/06/2024 Section Cited HSC 1569.153	1 2 3 4 5 6 7	"A theft and loss program shall be implemented by the residential care facilities for the elderly within 90 days after January 1, 1989. The program shall include all of the following [subsections (a) through (m)]." This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee agrees to update theft and loss policies and procedures and to provide LPA Moleski updated documentation when completed. vincent.moleski@dss.ca.gov
	8 9 10 11 12 13 14	Based on observation, interviews, and record reviews, all required elements of the theft and loss program per 1569.153(a)-(m) were not implemented, which poses a potential health, safety, and personal rights risk.	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: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent Moleski	TELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

LIC9099 (FAS) - (06/04)

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