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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005464
Report Date: 04/28/2022
Date Signed: 05/02/2022 02:46:35 PM


Document Has Been Signed on 05/02/2022 02:46 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 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:
04/28/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Jennell ReveraTIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 4/28/22 at 9:15AM. LPA met with Jennell Revera, Administrator and stated the purpose of today’s visit. Community Care Licensing (CCL) received an Incident Report (SIR) on 4/26/22 indicating that resident #1 (R1) left the facility without the knowledge of the staff.

LPA requested, received and reviewed the most recent Physician Report (LIC602) for R1 dated 1/5/21. The LIC602 stated that R1 was unable to leave unassisted and has a diagnosis of Dementia.

A review of R1's most recent assessment Individual Service Plan (ISP) dated 4/22/22 indicates that R1 utilized a wander guard that would be checked daily. It also indicated that R1 had a supervised elopement on 4/12/22 and an elopement on 4/22/22 during night shift.

LPA conducted interviews of Staff #1 (S1) - (S5) and family of R1 during this visit. LPA received information that R1 eloped previously on 4/22/22. Administrator stated that the incident was not reported.

Per the Administrator and the most recent assessment, effective 4/22/22, R1 was to receive 1:1 supervision during (NOC) shift hours of 10p-6am due to wandering behavior but the agency cancelled the shift at the last minute. Staff #2 (S2) was put in place for the 1:1 companion to ensure the supervision of R1.

LPA toured the facility with Administrator. LPA observed with Administrator and S3 that the door did not alarm when pushed opened outward. S3 does a weekly check on day mode and now conducts weekly checks on night mode as well.
LPA observed the room where R1 reside and the area that S2 was located to observe R1. Administrator stated that S2 did not look into R1's room as to be careful not to wake R1 as any disturbance would cause R1 to be awake all night.

See 809C for continuation...
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: CARLTON PLAZA OF ELK GROVE
FACILITY NUMBER: 347005464
VISIT DATE: 04/28/2022
NARRATIVE
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Administrator stated that a visual from the common area camera shows that R1 was at the front door pushing it to leave at 11:03pm on 4/25/22. And it is assumed that S2 was outside R1's room at 10:55pm. There is no fee being charged for the 1:1 companion. R1 was last seen physically during medication pass on 4/25/22 at approximately 8pm.

The SIR indicated that at 7:11am on 4/26/22, S4 noticed the front door opened. It also mentioned the alarm on the door did not activate. During a search of the facility and community R1 was located in a parking lot at 7:32am sitting on curb and pants were dirty by S5.

R1 was observed to have sustained a scrape on one hand it is unclear which hand. Due to R1 eating, first aid was not provided. Right after the meal, R1's family arrived to take R1 on an outing.

The investigation revealed that R1 eloped from the facility twice, one of which was not reported to CCL. On 4/26/22, R1 was out of the facility approximately 8 hours over night from 11:03pm 4/25/22 to 7:36am 4/26/22.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit.

If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Licensee was provided a copy of their rights (LIC9058 12/15) and their signature on this form acknowledges receipt of these rights.
An exit interview was conducted, and a copy of this report was provided.

See 809D for continuation...
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 05/02/2022 02:46 PM - 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
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: 04/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
04/29/2022
Section Cited

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Care of Persons with Dementia
In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including:
Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials.
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This requirement is not met as evidenced by: the resident awol'd twice from the facility
Based on the facility did not implement any new measures to prevent future awols from re-occurring. This possess an immediate health and safety risk to residents in care.
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Type A
04/29/2022
Section Cited

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Care of Persons with Dementia
The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.
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This requirement is not met as evidenced by: the resident awol'd twice from the facility and the front door alarm did not sound
Based on interviews the resident eloped out the front door. This possess an immediate health and safety risk to residents in care.
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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: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 05/02/2022 02:46 PM - 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
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: 04/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/29/2022
Section Cited

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Care of Persons with Dementia
The following initial and continuing requirements must be met…without violating Section 87468, Personal Rights, facility staff shall ensure the continued safety of residents if they wander away from the facility.
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This requirement is not met as evidenced by: R1 wandered from the facility at least twice.
Based on interviews and documentation, the Licensee did not ensure supervision resulting in R1 wandering away from the facility twice with the most recent being approximately 8 hours. This possess an immediate health and safety risk to residents in care.
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Type A
04/29/2022
Section Cited

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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: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 05/02/2022 02:46 PM - 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
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: 04/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
04/29/2022
Section Cited

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Reporting Requirements
Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:Any incident which threatens the welfare, safety or health of any resident...unexplained absence of any resident.
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This requirement is not met as evidenced by: A review of submitted SIRs of which one was not found for the previous date R1 AWOL'd on 4/22/22.
Based on interviews the Administrator did not submit a report for the AWOL incident that occurred on 4/22/22. This possess an immediate health and safety risk to residents in care.
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Deficiency Dismissed
Type A
04/29/2022
Section Cited

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Incidental Medical and Dental Care
In all facilities licensed for sixteen (16) persons or more...designated as having primary responsibility for assuring that each resident receives needed first aid...
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This requirement is not met as evidenced by:R1 did not receive first aid due to eating
Based on interviews the Administrator confirmed that R1 did not receive first aid because after eating the family took R1 on an outting. This possess an immediate health and safety risk to residents in care.
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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: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5