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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347005464
Report Date: 10/28/2021
Date Signed: 10/28/2021 03:08:54 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
09/28/2021 and conducted by Evaluator Tirzah Hubbard
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20210928085649
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:
10/28/2021
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Executive Director Jennell ReveraTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility refused to issue refund.
INVESTIGATION FINDINGS:
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On 10/28/21 Licensing Program Analysts (LPA)s Tirzah Hubbard and Charlie Yang conducted an unannounced complaint visit and was met by the facility designated Administrator Jennell Revera. A brief discussion was held with the facility designated Administrator.
The purpose of this visit was to deliver the findings for the above allegation.
Current census: 122
Based on Interviews and records review, S1 documented and provided a copy of the check issued out for the refund on 10/6/2021 to R1. This document provided the date and time when the check was issued and the amount that was refunded. It was learned that communication to retrieve additional information for the right account for this check to be paid out was not relayed by R1 and R1's responsible party in a timely manner. As a result, S1 did not receive the correct correspondence which caused the check to be deposited into the wrong account. S1 requested the correct account information for the second time, via telephone, for the correct account information on 10/11/21 in order to disperse the second check for the refund. On 10/11/21 S1 contacted the finance department to ensure the check was refunded back into the proper account and will provide notification when refund was dispersed.
Unsubstantiated
Estimated Days of Completion: 30
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tirzah HubbardTELEPHONE: 559-365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021
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 7
Control Number 27-AS-20210928085649
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: 10/28/2021
NARRATIVE
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The check was hand delivered by designated Administrator on 10-14-21.

Although the allegation may have happened or was valid, there was not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation was UNSUBSTANTIATED.

No deficiencies were cited on todays visit. An exit interview was held and a signature on this report acknowledged a copy was provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tirzah HubbardTELEPHONE: 559-365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 7
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
09/28/2021 and conducted by Evaluator Tirzah Hubbard
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20210928085649

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: 180DATE:
10/28/2021
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Jennell ReveraTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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9
Staff gave resident wrong medication.
INVESTIGATION FINDINGS:
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On 10-28-21 Licensing Program Analysts (LPA)s Tirzah Hubbard and Charlie Yang conducted an unannounced visit to discuss complaint allegations and deliver complaint findings. LPAs met with designated Administrator Jennell Revera. A brief discussion was held with the facility designated Administrator.
Census: 122
Based on observation, interviews and record review it was learned that two medication errors occurred on 5-27-21 and 9-26-21. On 5-27-21, R1 was administered the wrong dosage of 10 units with the wrong insulin type. On 9-26-21, it was learned that R1 was administered the wrong insulin along with the wrong dosage as well. The correct type of insulin and dosage for R1 should have been 5 units of Humalog each day. It was learned that the facility did not report each medication error to the Long Term Care Ombudsman and CCL when they occurred.

As a result this facility did not administer the correct medication to R1. This facility was deficient and therefore this complaint was SUBSTANTIATED.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tirzah HubbardTELEPHONE: 559-365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 27-AS-20210928085649
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: 10/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/28/2021
Section Cited
CCR
87465(a)(5)
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A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following. The licensee shall assist residents with self administered medications as needed.
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The facility will provide medication training for both medical technicians from 5-27-21 and 9-26-21 dates. Both Medical technicians have attended the medication trainging on 10-19-2021.
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This regulation was not met as evidenced by based on LPA’s interviews and a review of the facility records, this facility did not ensure that the correct medication was administered to R1 on 5-27-21 and 9-26-21. R1 received the wrong medication and dosage on each date.
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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: Tirzah HubbardTELEPHONE: 559-365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 27-AS-20210928085649
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: 10/28/2021
NARRATIVE
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Per the California Code of Regulations, Title 22, Division 6, Chapter 8, violations were observed during this complaint investigation. Deficiencies were cited on the 9099-D. An exit interview was conducted with designated Administrator Jennell Revera and a copy of this report was provided and signature confirmed receipt of these documents
Appeal rights were printed and given to the facility designated Administrator.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tirzah HubbardTELEPHONE: 559-365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 7
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
09/28/2021 and conducted by Evaluator Tirzah Hubbard
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20210928085649

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:
10/28/2021
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Jennell ReveraTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff did not provide meals to resident.

Staff did not follow residents modified diet.

Additional fees charged to resident was not specified.

Staff did not provide shower assistance to resident.

Staff did not have sufficient testing equipment for resident in care.
INVESTIGATION FINDINGS:
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On 10-28-21 Licensing Program Analysts (LPA)s TIrzah Hubbard and Charlie Yang conducted an unannounced complaint visit. LPAs were met by the facility designated Administrator Jennell Revera to discuss complaint allegations and to deliver complaint findings.
Census: 122
Based on interviews and information gathered during the course of this investigation, it was revealed that this facility provided meals to R1 each day of the week. Based on records review it was learned that staff followed the residents modified diet. LPA observed the modified diet consisted of R1 not consuming milk and sweets based on health conditions. Based on a records review and interviews it was learned that the facility specified additional fees for additional care for R1 in the lease and care plan agreement. In addition, the responsible party for R1 agreed to the charges. This facility agreed to refund the additional charges and remove the additional care as of 10-11-21.
Based on an interview with the facility designated Administrator, S1, it was learned the facility did adhere to the agreement and fees due were accurate.
Unfounded
Estimated Days of Completion: 30
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tirzah HubbardTELEPHONE: 559-365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 27-AS-20210928085649
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: 10/28/2021
NARRATIVE
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In addition, interviews conducted with R1 and record review concluded that the facility did provide shower assistance daily to R1 to ensure care plan needs were met.

Based on observation and record review, it was learned the facility had significant testing equipment for persons in care. LPA observed the testing kit and learned the facility obtained a new kit each month for persons in care. Deliveries from Premier Pharmacy were made every day based on R1's care plan and needs.
The preponderance of evidence standards has not been met. Therefore, the allegations were deemed to be UNFOUNDED. There were no deficiencies cited during this visit.

Exit Interview.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tirzah HubbardTELEPHONE: 559-365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021
LIC9099 (FAS) - (06/04)
Page: 7 of 7