Inspection Reports for Carlton Senior Living Elk Grove

Licensing Program Analysts arrived unannounced to open a complaint investigation but discovered an unrelated deficiency during the investigation.

A medication error was identified where a resident missed four daily doses of a Parkinson's disease medication due to a transcription error. Additionally, the facility failed to report the incident to the Community Care Licensing Division as required by regulation.

The visit was complaint-related, triggered by an unannounced complaint investigation. The medication error was substantiated, and the facility was cited for failure to report the incident as required by 22 CCR Section 87211(a)(1)(D).

The visit was an unannounced case management inspection triggered by an incident report received on July 28, 2025, concerning a resident who experienced complications related to medication-releasing intravaginal rings.

The inspection found that staff nurses had been inserting intravaginal rings without proper initial training, resulting in a resident receiving multiple rings beyond the recommended 90-day usage period, causing injury. The facility was cited for deficiencies related to medication mismanagement and lack of staff training, and a $500 civil penalty was assessed.

The visit was triggered by an incident report alleging improper management of intravaginal rings for a resident, which was substantiated by findings of medication mismanagement and lack of staff training.

The inspection was an unannounced case management visit triggered by an incident report received on 07/19/2025 regarding a resident who was missing during the evening medication pass and was found unsupervised in the community.

The facility failed to ensure the safety of a resident who was missing for approximately four hours while unsupervised in the community, posing an immediate health, safety, and personal rights risk. Surveillance footage showed a staff member at the front desk did not notice the resident leaving the facility.

The visit was complaint-related based on an incident report about a resident missing during medication pass time and found unsupervised in the community. The complaint was substantiated as the facility was cited for failure to supervise the resident.

An unannounced annual inspection was conducted by Licensing Program Analyst Vincent Moleski to evaluate compliance with licensing requirements at Carlton Plaza of Elk Grove.

The inspection found no deficiencies. The facility met all regulatory requirements including adequate furnishings, proper temperature controls, sufficient food supplies, and appropriate storage of medications and cleaning solutions.

The visit was an unannounced case management inspection conducted during a complaint investigation related to the care of a resident (R1) who was hospitalized following a period of quarantine and illness.

The investigation found that appropriate assistance was not provided to R1 during their quarantine period, leading to severe health complications. Additionally, the facility failed to submit a required incident report within seven days of R1's hospitalization.

The complaint investigation was triggered by concerns regarding the care of resident R1, who was hospitalized on 8/8/24 with serious medical conditions including lactic acidosis and acute renal insufficiency. Interviews and record reviews revealed inadequate monitoring and assistance during R1's quarantine and failure to report the incident timely.

The visit was an unannounced case management visit conducted by Licensing Program Analyst Vincent Moleski to review death reports and resident records for two residents.

No deficiencies were cited during this visit. The Licensing Program Analyst reviewed death reports and resident records and interviewed the facility administrator and a staff member regarding these reports.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2024-08-13 regarding concerns about the cleanliness of a resident's room and other care issues.

The investigation substantiated that staff did not ensure a resident's room was kept clean, specifically related to uncleaned cat feces posing health and safety risks. Allegations that a resident became dehydrated and developed sepsis, and that staff failed to administer medication as prescribed, were unsubstantiated.

The complaint alleged that staff did not ensure the resident's room was kept clean, that due to negligence the resident became dehydrated and developed sepsis resulting in hospitalization, and that staff did not administer the resident's medication as prescribed. The allegation regarding cleanliness was substantiated, while the allegations regarding dehydration, sepsis, and medication administration were unsubstantiated.

An unannounced annual inspection was conducted to evaluate compliance with licensing requirements and assess the facility's operations and resident care.

The inspection found deficiencies related to staff fingerprinting and annual medical assessments for residents with dementia. A civil penalty was assessed for an employee working without proper association and fingerprinting. The facility was otherwise found to have adequate supplies, environment, and resident care conditions.

The inspection was an unannounced complaint investigation triggered by allegations received on 2024-03-27 regarding inadequate food service, unmet toileting and showering needs, disrespectful treatment, overcharging, and medication mismanagement at Carlton Plaza of Elk Grove.

Based on interviews, observations, and record reviews, all allegations were found to be unsubstantiated with no deficiencies cited. Residents and staff interviews, as well as documentation reviews, showed no evidence of the alleged violations.

The complaint investigation was unsubstantiated, meaning there was insufficient evidence to prove the alleged violations occurred. Allegations included inadequate food service, unmet toileting and showering needs, disrespectful treatment, overcharging, and medication mismanagement.

The inspection was an unannounced complaint investigation triggered by allegations that facility staff did not safeguard residents' belongings.

The investigation found that the facility failed to implement several required elements of its theft and loss program, including lack of documentation of missing items, absence of estimated values for missing property, failure to conduct semiannual reviews of theft and loss procedures, and failure to provide required legal sections to the resident or responsible party. The allegation was substantiated.

The complaint was substantiated. The allegation was that facility staff did not safeguard residents' belongings. The investigation included interviews, observations, and record reviews, confirming deficiencies in the facility's theft and loss program.

The visit was an unannounced case management follow-up to verify the plan of correction for a citation issued on October 10, 2023.

No deficiencies were cited during this visit. The Licensing Program Analyst interviewed the facility administrator and staff, and an exit interview was conducted.

The inspection was an unannounced complaint investigation triggered by allegations that due to lack of staffing, staff do not answer resident call buttons timely, and that staff are not following infectious disease protocols.

The investigation substantiated the allegation of insufficient staffing leading to delayed response to resident call buttons, citing multiple instances of calls taking over 15 minutes to be answered. The allegation regarding failure to follow infectious disease protocols was unsubstantiated based on observations and interviews.

The complaint investigation was substantiated for the allegation that due to lack of staffing, staff do not answer resident call buttons timely. The allegation that staff are not following infectious disease protocols was unsubstantiated.

The visit was an unannounced case management follow-up to an incident report regarding an alleged theft in a resident's apartment.

The Licensing Program Analyst reviewed the incident involving theft of a ring and money, interviewed involved residents and staff, and found no deficiencies during the visit. Two staff members were terminated related to the incident.

An unannounced annual inspection was conducted to evaluate compliance with licensing requirements at Carlton Plaza of Elk Grove.

The inspection found expired first aid/CPR certifications for three staff members (S3, S4, and S7), posing a potential health and safety risk. Other facility conditions such as temperature, food supply, and safety equipment were compliant.

The visit was an unannounced follow-up on an incident report received on 2023-06-15 regarding a possible medication error involving a resident on 2023-06-06.

The investigation found that the medication administration records were followed as per instructions, but a medication bottle received was already opened and one tablet was missing. The resident did not experience any serious side effects, and the facility obtained a new medication order from the prescribing doctor. No deficiencies were cited during this visit.

The complaint involved a possible medication error reported by the responsible party of a resident. The medication was administered once instead of twice on 6/6/23, but no harm occurred. The complaint was investigated and found to be unsubstantiated with no deficiencies cited.

The visit was a case management visit conducted regarding the immediate exclusion of an employee.

No deficiencies were cited during this visit. The employee in question was terminated immediately after receiving the immediate exclusion letter.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-01-26 alleging that the facility was not following infection control procedures.

The investigation found that during a recent COVID-19 outbreak, staff did not dispose of gowns as required, with staff reusing disposable gowns instead of discarding them. This substantiated the allegation that the facility failed to follow infection control procedures.

The complaint was substantiated. The allegation that the facility was not following infection control procedures was validated based on staff interviews and administrator statements regarding PPE gown reuse during a shortage.

Unannounced case management visit in response to an unusual incident report for a resident who fell and suffered a fractured wrist.

No deficiencies were cited during this visit. Licensing Program Analysts reviewed resident records and care plans but were unable to speak with the resident or staff involved due to their absence.

The visit was an office meeting conducted by Licensing Program Analyst Jamie Ivey Canady with the facility administrator Jennell Revera to discuss facility incident reporting requirements based on Title 22 Regulations.

A deficiency was cited for failure to report a Covid-19 outbreak that began on 1/15/2023 within the regulatory timelines, posing an immediate health and safety risk to persons in care.

The visit was an unannounced complaint investigation regarding an allegation of lack of supervision resulting in resident wandering from the facility.

The investigation found the allegation to be unsubstantiated due to lack of evidence, and no deficiencies were cited.

The complaint was unsubstantiated as the preponderance of evidence standards were not met. The allegation involved lack of supervision resulting in resident wandering.

Licensing Program Analyst Ruth Wallace conducted an unannounced Required Annual 1 Year Inspection Visit to evaluate compliance with regulations and ensure resident safety.

The facility was found to be in full compliance with no deficiencies observed. The physical plant, safety systems, medication storage, kitchen, and resident files were all inspected and met regulatory standards.

Unannounced complaint investigation visit conducted due to multiple allegations including wrong medication administration, unskilled insulin injections, failure to ensure meals, short staffing, failure to provide services as per care plan, and unauthorized disclosure of resident information.

All allegations except one were found to be unsubstantiated after interviews, record reviews, and observations. One allegation regarding failure to provide a diabetic diet to a resident was substantiated, with evidence that a maple syrup product inconsistent with the prescribed diabetic diet was given to the resident.

Complaint investigation was unannounced and based on allegations received on 03/03/2022. The allegations included wrong medication administration, unskilled insulin injections, failure to ensure meals, short staffing, failure to provide services as per care plan, and unauthorized disclosure of resident information. All allegations were unsubstantiated except the diabetic diet allegation which was substantiated.

Unannounced complaint investigation visit conducted in response to allegations received on 2022-04-08 regarding resident hygiene, toileting needs, visitor restrictions, and medication management.

The investigation found the allegations regarding resident hygiene, toileting needs, and visitor restrictions to be unsubstantiated. However, the allegation of medication mismanagement was substantiated due to missing medication pills and inadequate documentation of medication administration.

Complaint investigation was unannounced and conducted by Licensing Program Analyst Michael Bilger. Allegations included unmet hygiene and toileting needs, prevention of visitors, and medication mismanagement. The hygiene, toileting, and visitor allegations were unsubstantiated. The medication mismanagement allegation was substantiated due to missing medication and poor documentation.

The inspection was conducted due to an incident report received on 2022-04-26 indicating that a resident (R1) left the facility without staff knowledge.

The investigation found that resident R1 eloped twice from the facility, including an unreported incident on 2022-04-22, and that the front door alarm did not activate during one elopement. The facility failed to implement adequate safety measures to prevent wandering and did not provide first aid after R1 sustained a scrape. The facility also failed to submit a required incident report for one elopement.

The visit was complaint-related due to an incident report of resident elopement. The complaint was substantiated as the resident eloped twice, one incident was unreported, and deficiencies were cited.

The inspection was an unannounced complaint investigation visit conducted to investigate multiple allegations including refusal to issue a refund, medication errors, failure to provide meals, failure to follow modified diet, unspecified additional fees, failure to provide shower assistance, and insufficient testing equipment.

The investigation found the refund allegation unsubstantiated with no deficiencies cited. However, the medication error allegation was substantiated with deficiencies cited related to incorrect medication administration on two occasions. Other allegations regarding meals, diet, fees, shower assistance, and testing equipment were found to be unfounded with no deficiencies cited.

The complaint investigation was triggered by allegations including refusal to issue refund, medication errors, failure to provide meals, failure to follow modified diet, unspecified additional fees, failure to provide shower assistance, and insufficient testing equipment. The medication error complaint was substantiated; the refund complaint was unsubstantiated; and the other allegations were unfounded.

The visit was an unannounced Required Annual 1 Year inspection conducted to evaluate compliance with licensing regulations.

The facility was found to be in good condition with no deficiencies observed. The physical plant, kitchen, courtyard, and safety equipment were all in compliance with regulations, and infection control measures for Covid-19 were in place.

Unannounced complaint investigation visit conducted in response to allegations including staff not meeting resident needs, resident left in soiled diapers, and resident room was malodorous.

The investigation found the allegations to be unsubstantiated with no deficiencies observed or cited. Interviews and document reviews indicated that care needs were addressed appropriately and no foul odors were detected in the resident's room.

Complaint was unsubstantiated as there was not a preponderance of evidence to prove the alleged violations occurred.

The visit was an unannounced virtual case management inspection conducted due to COVID-19 precautionary measures.

The facility was found to have deficiencies related to the absence of an administrator, facility manager, or designated substitute on the premises during the virtual visit, posing a potential health risk to residents.

The purpose of this office meeting is to discuss the COVID outbreak at the facility.

The facility discussed infection control measures including assigning an Infectious Control Lead, co-horting plan, and visitation restrictions. No deficiencies were cited at this time.