347005464-7-26-2021-27-AS-KHOS-C5BSRC-20210727140607

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347005464
Report Date: 07/23/2021
Date Signed: 07/26/2021 03:53:41 PM

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
09/08/2020 and conducted by Evaluator Charlie Yang

COMPLAINT CONTROL NUMBER: 27-AS-20200908090335

FACILITY NAME:	CARLTON PLAZA OF ELK GROVE		FACILITY NUMBER:	347005464
ADMINISTRATOR:	AMANDA SMITH		FACILITY TYPE:	740
ADDRESS:	6915 ELK GROVE BLVD.		TELEPHONE:	(916) 714-2404
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95758
CAPACITY:	180	CENSUS: 139	DATE:	07/23/2021
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Cal Mendiola and Janelle Rivera		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff not meeting resident needs.

Resident left in soiled diapers.

Resident room was malodorous

INVESTIGATION FINDINGS:

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Unannounced complaint visit made out to this facility on 07/23/2021 by LPA Charlie Yang who was met by the Resident Services Director Cal Mendiola and the newly appointed facility designated Administrator Janelle Rivera. Brief interview conducted with the Resident Services Director.
Current census was 139 residents.
Based on a review of the facility documents and interviews conducted, it was learned that R1 was initially admitted in 2017 and was a resident until the latter part of 2020. In that span of time it was observed that there was a total of 11 assessments conducted, Personal Services Plan Assessment, by this facility to address any care needs or changes involving R1. There were care notes and documentation addressing changes to the level of care for R1 as well. There was an updated LIC 602, Physician's Report, faxed into the responsible primary care physician for R1 which was completed on an annual basis.
Based on a review of the care notes it was observed that there were incidents of incontinence of bladder experienced by R1 but staff promptly responded and were able to address the issue. It was observed that there were other incidents involving this issue of incontinence but facility staff were present and able to assist.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2021

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-20200908090335

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: 07/23/2021

NARRATIVE

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Based on interviews and a review of the facility documents, it was never observed that the room for R1 was ever foul smelling or carried an odor that was offensive to R1 and facility staff. It was learned that housekeeping was present on a weekly basis as well as laundry services. Any additional services originally not specified in the Personal Services Plan Assessment would be provided at an additional cost to the resident and their responsible party.

As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegation may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred.

There were no deficiencies observed or cited at this time.

Exit Interview

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2021

LIC9099 (FAS) - (06/04)

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