347005464-12-30-2024-27-AS-VMOI-DCFP44-20241230095830

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347005464
Report Date: 12/30/2024
Date Signed: 12/30/2024 09:58:40 AM

Document Has Been Signed on 12/30/2024 09:58 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
ADMINISTRATOR/ DIRECTOR:	JENNELL REVERA		FACILITY TYPE:	740
ADDRESS:	6915 ELK GROVE BLVD.		TELEPHONE:	(916) 714-2404
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95758
CAPACITY: 180	TOTAL ENROLLED CHILDREN: 0	CENSUS: 140	DATE:	12/30/2024
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Jennell Revera		TIME VISIT/ INSPECTION COMPLETED:	10:00 AM

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	Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit. LPA Moleski met with facility administrator Jennell Revera and explained the purpose of the visit. During the course of a complaint investigation related to the care of a resident (R1), LPA Moleski conducted interviews with Revera, a resident (R1), three responsible parties for R1 (R1’s RPs 1-3) and 11 staff members (S1-S11). See complaint # 27-AS-20240813084041 for more details. This report addresses deficiencies discovered during that investigation. LPA Moleski reviewed R1’s progress notes from the days preceding R1’s hospitalization on 8/8/24. A note authored by S5 dated 8/1/24 indicated that R1 was tested positive for COVID-19. A note authored by S7 dated 8/2/24 indicated that R1 had a video appointment with their primary care physician. The note further indicated that during this appointment, R1’s physician "asked [R1] to keep [themselves] hydrated and report to staff any changes." Per S7’s note, R1 was “only having a cough, no sore throat and a runny rose [sic]” at the time. S7 also indicated that R1 was prescribed and given Paxlovid to treat R1’s COVID-19. LPA Moleski reviewed an internal facility incident report, dated 8/8/24, which described R1 suffering from increased confusion. R1’s responsible parties called for emergency medical services, and R1 was taken to the hospital for treatment, according to the internal incident report. The Community Care Licensing Division did not receive an incident report regarding this incident within seven days, as required per 22 CCR 87211(a)(1)(D). LPA Moleski reviewed medical records related to R1’s hospitalization on 8/8/24. According to R1’s medical records, R1 was diagnosed with lactic acidosis, acute renal insufficiency, hyponatremia, and leukocytosis upon admission to the emergency room. [continued on 809-C]

Stephen Richardson	TELEPHONE: (916) 263-4746
Vincent Moleski	TELEPHONE: (559) 365-5294
	DATE: 12/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024

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

LIC809 (FAS) - (06/04)

Page: 1 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 12/30/2024

NARRATIVE

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R1 was given intravenous fluids and was prescribed an antibiotic while in the hospital. R1’s was assessed to have "severe intravascular volume depletion causing lactic acidosis" and "acute renal insufficiency due to poor oral intake and med/viral syndrome induced diarrhea due to Paxlovid and COVID-19 viral infection." Later in this same assessment, R1’s lactic acid elevation was said to be "likely due to poor oral intake plus diarrhea due to Paxlovid and COVID-19 viral infection." Notes regarding R1’s diarrhea indicated that it is a "noted side effect of Paxlovid and also could be COVID related as well."

In an interview, Revera said that R1 was independent at the time, and did not have any care tasks regularly assigned to caregivers. Revera said that during R1’s quarantine, R1 was not receiving regular check-ins from caregivers, but was visited daily by medication technicians to pass R1 their medications. Revera said that additional check-ins from nurses and caregivers have since been arranged for residents not receiving regular care while on quarantine in order to monitor their condition.

In an interview, S7 said that R1 had voiced during their video appointment on 8/2/24 that they were not drinking much water. LPA Moleski interviewed S3, S8, S9, S10, and S11, medication technicians who visited R1 during their quarantine period prior to their hospitalization on 8/8/24. S3, S8 and S9 said they were not aware of any reason that R1 would have been dehydrated, and were not aware of any need to remind R1 to stay hydrated.

S9, who said they visited R1 on all five days of R1’s five-day quarantine, described R1 as “really, really sick” during their quarantine. S9 said that throughout the five-day quarantine, R1 was not eating or drinking much. S9 said that they noticed from the first day of R1’s quarantine that R1’s food trays were untouched. S9 said they would have kitchen staff prepare a smoothie for R1 daily in an attempt to encourage R1 to eat and drink, but R1 would only have one or two sips. S9 said that they did not feel R1 needed to be sent to the hospital earlier, but added that they informed their manager, S7, about R1’s condition. S9 said that R1 was able to sit up and take their medications with encouragement, but it was difficult for R1 because they were very tired. S9 said R1 was sleeping a lot during quarantine.

[continued on 809-C]

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent Moleski	TELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 12/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024

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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CARLTON PLAZA OF ELK GROVE	FACILITY NUMBER: 347005464
	VISIT DATE: 12/30/2024

NARRATIVE

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S11 passed medications to R1 four times between 8/2/24 and 8/7/24, according to R1’s medication administration records (MARs). S11 said that R1 was “not looking normal” and “not looking good” on one of those days. S11 said that R1 had a reduced appetite, and said that R1 told S11 that R1 did not want to eat. S11 said they did not check R1’s food trays to see how much R1 was eating. S11 said they did not feel R1 needed to be sent to the hospital sooner. S11 was not aware of any reason why R1 would be dehydrated, or why R1 might need reminders to stay hydrated.

R1’s RP 1-2 said that they decided to visit R1 on 8/8/24 because they were not receiving responses to text messages sent to R1. R1’s RP 1-2 expressed surprise at seeing R1’s condition on 8/8/24. R1’s RP 2 said that R1 was unresponsive when they arrived. R1’s RP 1 said R1 looked so ill they thought R1 had died. R1’s RP 2 said they then called R1’s physician, who instructed them to call 911.

This facility is hereby cited per 22 CCR Sections 87211(a)(1)(D) and 87466. An exit interview was held with Revera. Appeal rights and a copy of this report were left with Revera.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent Moleski	TELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 12/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/30/2024 09:58 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 12/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

“The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.” This requirement was not met as evidenced by:
	Deficient Practice Statement
1 2 3 4
	POC Due Date: 12/31/2024
	Plan of Correction
1 2 3 4	Licensee agrees to provide LPA Moleski with a written plan regarding monitoring and observation of residents on quarantine by POC due date. Licensee agrees to include details in this written plan regarding the scheduling of a future staff training regarding observation of residents. Licensee further agrees to send LPA Moleski a sign-off sheet after this training is held. vincent.moleski@dss.ca.gov

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Stephen Richardson	TELEPHONE: (916) 263-4746
Vincent Moleski	TELEPHONE: (559) 365-5294
	DATE: 12/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024

LIC809 (FAS) - (06/04)

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