Inspection Reports for Carlton Senior Living Davis

The inspection was an unannounced case management follow-up visit to verify the Immediate Exclusion of Staff member S1 from the facility.

The Licensing Program Analyst verified that the excluded staff member S1 was no longer employed or present at the facility. No deficiencies were cited during the inspection.

The inspection was an unannounced complaint investigation visit triggered by multiple allegations received on 2025-02-19 regarding staff response times to resident calls, adherence to care plans, resident repositioning, prevention of inappropriate behavior, and reporting requirements.

The investigation substantiated that staff did not respond to residents' call lights in a timely manner and did not follow residents' care plans, specifically regarding two-person assistance. The allegations that staff did not ensure resident repositioning and did not prevent inappropriate behavior were unsubstantiated. The allegation that staff did not follow reporting requirements was unfounded.

The complaint investigation was substantiated for allegations that staff did not respond timely to call lights and did not follow care plans, including failure to use two-person assistance as required. The allegations regarding failure to reposition residents and prevent inappropriate behavior were unsubstantiated. The allegation regarding failure to follow reporting requirements was unfounded.

Unannounced Plan of Correction (POC) inspection conducted to verify correction of previous deficiencies.

The facility was found to be clean and residents were appropriately cared for. Door alarms and delayed egress alarms were functioning properly. The Plan of Correction has been cleared with no deficiencies or citations issued at the time of inspection.

The visit was conducted as a Case Management - Incident Visit to follow up on a self-reported incident involving a resident elopement reported to Community Care Licensing.

The facility failed to provide adequate supervision to a resident with dementia who eloped from the community, resulting in an immediate risk to the resident's health and safety. A civil penalty of $500 was issued for Zero Tolerance, Absence of Supervision.

The visit was complaint-related, following a self-reported incident where Resident 1, diagnosed with dementia and unable to leave unassisted, eloped from the facility on 04/20/2025. The resident was found safe off premises 2.4 miles away. The complaint was substantiated with a deficiency cited and a civil penalty issued.

An unannounced complaint investigation was conducted regarding allegations that staff were not taking precautions to mitigate the spread of illness in the facility.

The investigation found that the facility did not notify the Department within the required 24-hour timeframe about an outbreak of illness, substantiating the allegation. Several residents experienced vomiting and diarrhea, and the facility failed to report the outbreak timely as required by regulations.

The complaint alleged that staff were not taking precautions to mitigate the spread of illness. The allegation was substantiated based on evidence that the Administrator did not notify the Department in the required timeframe.

The inspection was an unannounced 1-Year Required Annual Inspection conducted to ensure the health and safety of residents in care.

The facility was observed to be clean, in good repair, and odor-free with necessary safety features in place. No immediate health, safety, or personal rights violations were observed, and all required documentation in resident and staff files was found.

An unannounced Case Management visit was conducted to follow up on substantiated complaint allegations regarding neglect, lack of care and supervision resulting in severe injury and facility disrepair.

The investigation substantiated neglect and lack of supervision leading to a resident (R1), identified as a fall risk, exiting the patio door unsupervised and falling outside, resulting in a fractured hip requiring hospitalization and surgery. A civil penalty of $9,500 was issued for serious bodily injury.

Complaint number 21-AS-20230724142905 was substantiated for neglect and lack of care and supervision resulting in severe injury and facility disrepair.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 07/22/2024 regarding inadequate toileting, food service, odor control, and addressing residents' condition changes.

Based on observations, interviews, and records reviewed during visits on 07/24/2024 and 10/19/2024, there was no evidence to substantiate any of the allegations. Staff were found to provide adequate food service, maintain cleanliness and odor control, address changes in residents' conditions, and meet residents' toileting needs in a timely manner.

The complaint included allegations that staff did not ensure timely toileting, did not provide adequate food service, did not keep the facility free from odor, and did not address changes in residents' physical, medical, mental, and social conditions. All allegations were found to be unsubstantiated.

The visit was an informal meeting conducted to discuss an incident that occurred on February 17, 2023, which resulted in a complaint investigation with substantiated findings, and to address areas of concern including staffing and administrator duties.

No deficiencies were cited during the informal conference office visit. The facility has implemented staffing improvements such as an evening supervisor and a 'hero position' to oversee operations and provide additional staff where needed.

The visit was related to a complaint investigation with substantiated findings from an incident on February 17, 2023.

The visit was a Case Management - Incident inspection conducted to follow up on a self-reported incident involving residents R1 and R2.

No deficiencies were found at the time of the visit and no citations were issued. The facility has been in contact with Police, Community Care Licensing, and the Ombudsman’s Office.

The visit was triggered by a self-reported incident report submitted to Community Care Licensing regarding residents R1 and R2. The Licensing Program Analyst reviewed incident details, gathered records, and took statements from the Administrator. Further follow-up will occur once additional information is gathered.

An unannounced annual required 1-year inspection was conducted to evaluate compliance with regulations at Carlton Plaza of Davis.

The facility was found to be clean, well-maintained, and compliant with regulations. No deficiencies or citations were issued during the inspection.

Unannounced case management visit to investigate deficiencies related to failure to report an incident as required by regulation.

The facility failed to report an incident to the Community Care Licensing Regional Office due to a 'failed to send' notification that was not resent, resulting in the incident going unreported and posing a possible threat to resident health and safety.

Investigation revealed the facility did not report the incident as required. Staff attempted to send the report but received a 'failed to send' notification and did not resend, leading to the incident going unreported.

Unannounced complaint investigation visit conducted due to allegations of neglect/lack of care and supervision resulting in severe injury and facility disrepair.

Investigation substantiated neglect by staff resulting in a resident exiting the facility unsupervised, leading to a fall and hip fracture requiring hospitalization. Additionally, poor lighting in the patio area contributed to the fall and injury, confirming the facility was in disrepair.

Complaint was substantiated. The resident was left outside unsupervised for approximately one and a half hours, resulting in a hip fracture requiring surgery. Facility lighting issues were also substantiated as contributing factors.

The visit was an unannounced case management inspection to follow up on a self-reported incident involving resident R1 and staff S1.

The facility was found to be operating with COVID-19 protocols in place, including visitor screening and mask requirements. No deficiencies or citations were found at the time of the visit.

The visit was triggered by a self-reported incident report submitted to Community Care Licensing regarding resident R1 and staff S1. The facility has been in contact with Police, CCL, and Ombudsman’s Office. The Licensing Program Analyst will review information and follow up once additional information is gathered.

An unannounced Annual Required – 1 year Infection Control inspection was conducted at Carlton Plaza of Davis.

The facility was found to be clean, with proper infection control measures in place, including mask-wearing by staff and proper food storage. No deficiencies or citations were issued during this inspection.

Unannounced visit/investigation of a complaint received on 2022-09-02 alleging the facility did not notice a change of resident condition.

The investigation included a tour, record review, and interviews. Although the allegation may have happened or is valid, there was insufficient evidence to prove the violation occurred, resulting in an unsubstantiated finding with no deficiencies or citations issued.

The complaint alleged the facility did not notice a change in condition of resident (R1). The allegation was found unsubstantiated due to lack of preponderance of evidence.

An unannounced inspection was conducted focusing on Covid-19 protocols following recent reported cases in the Memory Care Unit.

No deficiencies or citations were found during the inspection. The facility was clean, residents were well-groomed, and staff were observed following Covid-19 safety protocols including mask and glove use.

The inspection was an unannounced case management visit to check on the facility's hydration program for residents and review the Infection Control Plan.

No deficiencies or citations were found during the inspection. The facility has an Infection Control Plan being compiled, with six nurses designated as Infection Control Preventionists, and a hydration program in Memory Care with a variety of drinks offered to residents.

The inspection was an unannounced complaint investigation triggered by an allegation of questionable death and other complaints including neglect, lack of supervision, and failure to provide adequate care.

The investigation found the allegation of questionable death to be unfounded with no citations issued. Other allegations related to neglect, hygiene, food service, falls, and medical attention were unsubstantiated due to insufficient evidence, and no citations were issued.

The complaint investigation was initiated due to allegations including questionable death, neglect/lack of supervision resulting in pressure injuries and falls, failure to meet hygiene needs, failure to provide food service, and failure to ensure timely medical attention. The questionable death allegation was found unfounded, and other allegations were unsubstantiated.

An unannounced complaint investigation was conducted in response to allegations that residents were not being provided services and that the facility was not staffed adequately.

The investigation found that residents were being fed regularly, receiving bathroom and grooming assistance, and showering assistance was provided. Staffing records showed adequate staff to meet resident needs. The allegations were unsubstantiated and no citations were issued.

The complaint was unsubstantiated due to lack of preponderance of evidence to prove the alleged violations occurred.

The inspection was an unannounced complaint investigation triggered by allegations including a resident not being provided bed linens and the facility not following proper COVID-19 protocols.

The investigation substantiated both allegations: the resident's bed was not made correctly lacking proper bottom sheets on multiple occasions, and staff failed to properly doff, discard, and store PPE during an active COVID-19 case, violating infection control requirements.

The complaint was substantiated based on evidence including photographs, observations, interviews, and record reviews. The allegations of improper provision of bed linens and failure to follow COVID-19 PPE protocols were validated.

An unannounced Annual Required – 1 year Infection Control inspection was conducted at Carlton Plaza of Davis.

The facility was found to be clean, with proper infection control measures in place including PPE usage and Covid-19 protocols. No deficiencies or citations were issued during this inspection.