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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347005464
Report Date: 05/16/2022
Date Signed: 05/16/2022 03:40:38 PM

Unsubstantiated


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
04/08/2022 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20220408164306
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:
05/16/2022
UNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Jennell ReveraTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Resident's hygiene needs are not met
Resident's toileting needs are not met
Staff prevent resident from having visitors
INVESTIGATION FINDINGS:
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On 5/16/22 at 11:05am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to continue investigation and deliver findings for the complaint allegations noted above. LPA met with Administrator Jennell Revera and explained the purpose of the visit. During this investigation, LPA interviewed Administrator, Staff1 (S1), S2, S3, and Resident1 (R1). LPA also reviewed service plan for R1, care log of March and April of 2022 for R1, physician report for R1, and visitation log of last 30 days for memory care.

Allegation #1: Resident’s hygiene needs are not met. LPA interviewed Administrator, S1, S2, and S3. LPA also reviewed care log sheets for R1, service plan for R1, physician’s report for R1, and interviewed R1. Based on record reviews, and interviews it was determined that the service plan addressed needs for R1 which includes grooming, dressing, and bathing needs. It was further revealed through care log documentation that R1 consistently exercised resident right of refusing this care offered by staff. A review of service plan revealed interventions are in place to address R1’s refusal of care. {Cont. on 9099C}
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2022
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 5
Control Number 27-AS-20220408164306
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: 05/16/2022
NARRATIVE
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An interview with R1 states R1 is receiving hygiene care attempts by staff. Based on interviews and record reviews, it is determined that there is not a preponderance of evidence to conclude R1’s hygiene needs are not met or not being attended to by staff, therefore, this allegation is UNSUBSTANTIATED.

Allegation #2: Resident’s toileting needs are not met. LPA interviewed Administrator, S1, S2, and S3. LPA also reviewed care log sheets for R1, service plan for R1, physician’s report for R1, and interviewed R1. Based on record reviews, and interviews it was determined that the service plan addressed needs for R1 which includes full toileting assistance. It was further revealed through care log documentation that R1 consistently exercised resident right of refusing toileting assistance offered by staff. A review of service plan revealed interventions are in place to address R1’s refusal of care. An interview with R1 states R1 is receiving toileting assistance attempts by staff. Based on interviews and record reviews, it is determined that there is not a preponderance of evidence to conclude R1’s toileting needs are not met or not being attended to by staff, therefore, this allegation is UNSUBSTANTIATED.

Allegation #3; Staff prevent resident from having visitors. Allegation stated facility has isolated R1 from having in person visits and phone calls. LPA interviewed Administrator, S1, S2, S3, and R1. LPA also reviewed facility visitation log. Based on interviews, it was revealed that R1 is allowed visitors and phone calls. It was also revealed through interviews that R1 occasionally declines phone calls. Visitation log observed by LPA indicates R1 received in-person visits during March 2022 and April 2022. LPA also tested facilities phone communication system in memory care to ensure functionality. Phone system functioned appropriately during LPA's visit. Based on interviews and record reviews, there is not a preponderance of evidence to conclude that facility is isolating R1 from having visitors or phone calls, and this allegation is UNSUBSTANTIATED.

An exit interview was conducted with Jennell Revera and a copy of this report was left with Jennell. Appeal Rights provided.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
04/08/2022 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20220408164306

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:
05/16/2022
UNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Jennell ReveraTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Residents medications are mismanaged
INVESTIGATION FINDINGS:
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On 5-16-22 at 11:05am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver findings for the complaint allegation noted above. LPA met with Administrator Jennell Revera and explained the purpose of the visit. During this investigation, LPA interviewed Administrator, Staff1 (S1), S2, and S3.. LPA also conducted a medication audit for R1 on 5-16-22. LPA reviewed medication log sheets and physician orders dated March 2022-April 2022 for R1. LPA also reviewed medication log sheets for January to February of 2022 and July to December of 2021. Additionally, LPA reviewed physician report for R1 dated 3-21-22, and centrally stored medication log for R1 Based on record review, it was determined that R1 has physician orders in place which match medication log sheets. Physician’s report indicates R1s physician is to be called prior to administration of as needed medication. LPA did not observe additional medication beyond physician orders during medication audit for R1.

{Cont. on 9099C}
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2022
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 5
Control Number 27-AS-20220408164306
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: 05/16/2022
NARRATIVE
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 During medication audit for R1 it was revealed that a Quetiapine medication order for 25 milligrams (mg) is to be given 1 tab twice per day as needed for agitation and behavior. A medication count of the Quetiapine order as noted above for R1 was conducted during audit by S4 with Administrator and LPA present. Medication count revealed that 60 tablets were filled on 7/17/21 with 38 tablets remaining in bottle as of 5/16/22. Medication log sheets reviewed indicate R1 did not receive Quetiapine since its fill date of 7/17/21. Based on interview and record review, it was determined that there are no records existing which include a physician’s order or pharmacy change relating to the Quetiapine medication order noted above. Based on interviews, it was revealed that staff is instructed to assist R1 with medications as ordered and notify R1’s physician of any changes in condition. Based on the records reviewed and interviews conducted, it is determined that facility did not adequately manage the Quetiapine medication order for R1 in that a total of 22 pills are missing from the Quetiapine medication bottle with label reading and matching the physician’s order of 1 tablet twice per day as needed for agitation and behavior. Additionally, it is determined that this medication is not properly documented, in that accompanying documentation for this medication did not include when medication may have been given, the dosage taken, and R1s response to this medication. Additionally, R1’s medication log sheets indicate this medication was not given since it’s fill date, which is inconsistent with medication count conducted. Based on interviews conducted, records reviewed, and medication audit conducted, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED.

Citations are issued today under Title 22, Division 6, Chapter 8. An exit interview was conducted with Jennell Revera and a copy of this report was given to Jennell. Appeal rights provided.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20220408164306
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: 05/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/17/2022
Section Cited
CCR
87465(d)(3)
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87465 Incidental Medical and Dental Care. (d) If the resident is unable to determine his/her own need for a...nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff..., shall be permitted to assist the resident with self-administration provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.
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Licensee to conduct medication training for all appropriate staff. Training to include but not be limited to: medication documentation, physician’s orders, assisting residents with self-administration of medication. Training date to be submitted to LPA by POC due date. Proof of completed training to be submitted to LPA within 2 days of full completion. Full completion date shall not exceed 14 days from today’s date of 5-16-22.
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This requirement is not met as evidenced by: Based on interview and record review, a Quetiapine as needed medication for R1 is missing 22 pills from original container filled on 7/17/21 with no record from staff to indicate when medication was given, dosage taken, and R1s response to medication. This poses an immediate health and safety risk to residents in care.
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Licensee to conduct a full medication audit for memory care residents including but not limited to medication orders with matching medication log sheets and central storage records, medication counts, and accompanying medication documentations. Date of audit start to be submitted to LPA by POC due date and completed audit results to be submitted to LPA within 2 days of full completion. Full completion date shall not exceed 14 days from today’s date of 5-16-22.
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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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5