Inspection Report Summary
Most inspections at Carlton Senior Living Sacramento were clean and found the facility in compliance with regulations, including the most recent annual inspection on October 8, 2025, which had no deficiencies. However, several complaint investigations between 2023 and 2025 substantiated issues related to resident care, particularly inadequate supervision leading to falls and neglect of incontinent care, as well as violations of residents’ personal rights. The facility received two civil penalties of $500 each for these deficiencies, with no license suspensions or revocations listed in the available reports. Several other complaint investigations were unsubstantiated, including allegations of medication mismanagement and abuse. The trend shows improvement with the latest annual inspection being clean after earlier substantiated complaints and penalties.
Deficiencies per Year
4
3
2
1
0
High
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 7
Capacity: 185
Deficiencies: 0
Oct 8, 2025
Visit Reason
An unannounced annual inspection was conducted to evaluate compliance with licensing requirements at Carlton Senior Living Sacramento.
Findings
The inspection found the facility to be in compliance with all applicable regulations, including food safety, medication management, resident room safety, and staff background clearances. No deficiencies were cited during the visit.
Report Facts
Staff response time to call alert pendant: 142
Staff response time to call alert pendant: 137
Hot water temperature: 117.9
Food inventory duration: 7
Food inventory duration: 2
Facility capacity: 185
Resident census: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kasie Wimmer | Administrator / Executive Director | Named as the Designated Facility Administrator / Executive Director, not available for interview |
| Cal Mendiola | Designee | Met with Licensing Program Analyst during inspection and exit interview |
| Kimberly Viarella | Licensing Program Analyst | Conducted the inspection and authored the report |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 142
Capacity: 185
Deficiencies: 2
May 22, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that staff were not meeting a resident's care needs.
Findings
The investigation substantiated that resident R1 was not receiving necessary incontinent care, with multiple documented incidents of neglect. The resident had multiple falls without an updated strategic fall prevention plan, posing an immediate threat to health and safety.
Complaint Details
The complaint was substantiated. The allegation that staff were not meeting the resident's care needs was confirmed based on records and interviews. The resident had multiple incidents of unmet incontinent care and falls without appropriate care plan updates.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure incontinent residents are kept clean and dry as required by CCR 87625(b)(3). | Type A |
| Failure to ensure care and supervision changes were made following reappraisals, including lack of a strategic fall prevention plan as required by CCR 87463(g). | Type A |
Report Facts
Falls reported: 5
Weight gain: 18
Deficiency citations: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Viarella | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report. |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
| Cal Mendiola | Facility representative interviewed during the investigation. |
Inspection Report
Complaint Investigation
Census: 142
Capacity: 185
Deficiencies: 1
May 22, 2025
Visit Reason
The inspection was an unannounced case management visit regarding an incident reported by the Memory Care Director involving resident interactions and potential personal rights violations.
Findings
The facility was found to have violated a resident's personal rights when one resident was found in another resident's room without consent, posing an immediate risk to health, safety, and personal rights. The facility was cited for a Type A deficiency related to this violation and planned to conduct staff in-service training on personal rights.
Complaint Details
The visit was triggered by a complaint/incident involving R2 entering R1's room without consent. R1 was non-ambulatory and unable to consent. Staff interviews revealed that R2 had a history of aggressive behavior and fixation on R1. The complaint was substantiated by the findings of a personal rights violation.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Residents in all residential care facilities shall have all of the following personal rights: to be accorded dignity in their personal relationships. The licensee did not ensure this requirement was enforced, evidenced by R1's personal rights being violated when R1 was not accorded dignity in their personal relationships. | Type A |
Report Facts
Capacity: 185
Census: 142
Plan of Correction Due Date: May 23, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Viarella | Licensing Program Analyst | Conducted the inspection and authored the report |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager overseeing the inspection |
| Cal Mendiola | Designated Facility Administrator/Executive Director met during inspection |
Inspection Report
Complaint Investigation
Capacity: 185
Deficiencies: 1
Jan 23, 2025
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 2024-06-24 regarding personal rights and resident falls at Carlton Senior Living Sacramento.
Findings
The investigation found that resident R1, identified as a fall risk, sustained multiple falls resulting in serious injury and death. The facility failed to provide adequate supervision and did not update or implement effective fall risk mitigation strategies. Staff interviews revealed inconsistent resident checks and unclear supervision responsibilities. The allegation was substantiated.
Complaint Details
The complaint was substantiated. Resident R1 sustained multiple falls, including one that resulted in death due to intraparenchymal hemorrhage from a ground level fall. The facility failed to supervise R1 adequately and did not update care plans to mitigate fall risks. Staff schedules and supervision in the common area were unclear. A civil penalty of $500 was assessed with additional penalties under evaluation.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The licensee did not ensure resident needs were met as evidenced by failure to mitigate fall risks and provide adequate supervision. | Type A |
Report Facts
Capacity: 185
Civil penalty amount: 500
Number of falls documented for R1: 5
Plan of Correction due date: 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kasie Wimmer | Administrator | Facility Administrator met during investigation and received report |
| Kimberly Viarella | Licensing Program Analyst | Conducted the complaint investigation visit |
| Stephen Richardson | Licensing Program Manager | Oversaw licensing program and signed report |
Inspection Report
Annual Inspection
Census: 150
Capacity: 185
Deficiencies: 0
Sep 17, 2024
Visit Reason
The inspection was an unannounced Required - 1 Year visit conducted to evaluate compliance with licensing regulations and ensure safety and proper operation of the facility.
Findings
No deficiencies were cited during this visit. The facility was found to be in compliance with regulations including safety measures, medication storage, emergency preparedness, and staff and resident file reviews.
Report Facts
Residents receiving hospice care: 8
Non-ambulatory residents allowed: 120
Residents allowed to receive hospice care: 20
Inspection duration hours: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kasie Wimmer | Administrator | Met with Licensing Program Analyst during inspection |
| Victoria Brown | Licensing Program Analyst | Conducted the inspection visit |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Renewal
Census: 150
Capacity: 185
Deficiencies: 0
Sep 17, 2024
Visit Reason
The visit was an unannounced post-licensing inspection conducted to fulfill the required 1-year visit for facility licensing compliance.
Findings
The inspection found no deficiencies. The facility met all regulatory requirements including safety, medication storage, emergency preparedness, and environmental conditions.
Report Facts
Residents receiving hospice care: 8
Temperature thermostat: 75
Hot water temperature: 114.2
Emergency drill date: Aug 29, 2024
2-day perishables observed: 2
7-day non-perishables observed: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Brown | Licensing Program Analyst | Conducted the inspection and met with the facility administrator |
| Kasie Wimmer | Administrator | Facility administrator met during the inspection |
Inspection Report
Complaint Investigation
Census: 153
Capacity: 185
Deficiencies: 0
Sep 10, 2024
Visit Reason
Unannounced investigation of a complaint received on 2024-09-05 regarding allegations of staff mismanaging resident medication, failure to obtain a hospice care plan, and not maintaining a comfortable temperature for a resident.
Findings
The investigation found that the resident in question does not reside at the facility. Based on an interview with the Executive Director/Administrator Kasie Wimmer, all allegations were deemed unfounded, meaning the allegations were false or without reasonable basis. No deficiencies were observed or cited.
Complaint Details
Complaint was investigated and deemed unfounded. The allegations were dismissed as false or without reasonable basis.
Report Facts
Capacity: 185
Census: 153
Estimated Days of Completion: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kasie Wimmer | Executive Director/Administrator | Met with Licensing Program Analyst during investigation and provided information leading to unfounded determination |
| Victoria Brown | Licensing Program Analyst | Conducted the complaint investigation visit |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 142
Capacity: 185
Deficiencies: 0
Jun 20, 2024
Visit Reason
The inspection visit was an unannounced complaint investigation triggered by an allegation that facility staff sexually abused a resident in care.
Findings
The investigation included interviews with the resident and witnesses, and a review of multiple facility documents. The resident was unable to identify a suspect, and the information received did not result in a credible source to substantiate the allegation. The allegation was determined to be unsubstantiated.
Complaint Details
The complaint alleged that facility staff sexually abused a resident in care. The allegation was found to be unsubstantiated due to lack of credible evidence.
Report Facts
Complaint Control Number: 27-AS-20240506161153
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Bilger | Licensing Program Analyst | Conducted the complaint investigation and delivered findings. |
| Kasie Wimmer | Administrator | Met with Licensing Program Analyst during the investigation. |
| Liza King | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
Inspection Report
Annual Inspection
Census: 135
Capacity: 185
Deficiencies: 0
Sep 6, 2023
Visit Reason
Unannounced required 1 year annual inspection visit to evaluate the facility's compliance with health and safety regulations and licensing requirements.
Findings
The facility was found to be clean, odor-free, and in good repair with all required furniture and safety features present. No deficiencies were cited during the inspection. Staff and resident files were complete with all staff having criminal record clearance.
Report Facts
Water temperature: 110.7
Capacity: 185
Census: 135
Fire extinguisher inspection date: 2023
Staff files reviewed: 6
Resident files reviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kasie Wimmer | Administrator | Met with Licensing Program Analyst during inspection and participated in exit interview |
| Ruth Wallace | Licensing Program Analyst | Conducted the unannounced required 1 year annual inspection visit |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 146
Capacity: 185
Deficiencies: 1
Jul 26, 2023
Visit Reason
An unannounced Case Management visit was conducted to address concerns regarding a resident's elopement on 7/23/2023.
Findings
Resident R1, who was determined unable to leave the facility unassisted, eloped through the rear gate without staff knowledge. Staff mistakenly reset the alarm and delayed egress, allowing the elopement. The resident was found without injury. Deficiencies were cited and a civil penalty of $500 was assessed for immediate violations.
Complaint Details
The visit was complaint-related due to a resident's elopement incident on 7/23/2023. The resident was identified as unable to leave unassisted by physician order. The complaint was substantiated as deficiencies were cited and civil penalties assessed.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Care of Persons with Dementia: Facility staff failed to redirect a resident who attempted to leave the facility, violating Personal Rights under Section 87468. | Type A |
Report Facts
Civil penalty amount: 500
Deficiency count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kasie Wimmer | Administrator | Met with Licensing Program Analyst during visit and involved in incident review |
| Tung Truong | Licensing Program Analyst | Conducted the unannounced Case Management visit and authored the report |
| Czarrina A Camilon-Lee | Licensing Program Manager | Supervisor overseeing the licensing evaluation |
Inspection Report
Original Licensing
Census: 170
Capacity: 185
Deficiencies: 0
Sep 16, 2022
Visit Reason
Unannounced prelicensing visit conducted to evaluate the facility for licensing purposes.
Findings
The facility was found to be in compliance with all evaluated areas including resident care, safety, food storage, medication security, and emergency systems. Resident rooms, common areas, and safety equipment were observed to be sufficient and in good repair.
Report Facts
Residents under hospice care: 3
Residents receiving home health services: 16
Bedridden residents: 4
Hospice waiver capacity: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kasie Wimmer | Administrator | Facility designated Administrator met during inspection and involved in interview |
| Emanuel Dirar | Participated in brief interview during inspection | |
| Charlie Yang | Licensing Program Analyst | Conducted the inspection visit |
Inspection Report
Original Licensing
Capacity: 185
Deficiencies: 0
Sep 12, 2022
Visit Reason
The visit was conducted as part of the pre-licensing evaluation (COMP II) for Carlton Senior Living Sacramento to verify the applicant/administrator's understanding of California Code Title 22 Regulations and readiness for licensing.
Findings
The applicant and administrator demonstrated understanding of facility operation, admission policies, staffing requirements, restrictive health conditions, general provisions, emergency preparedness, complaints and reporting, and pre-licensing readiness. Identification was verified and required documentation was obtained.
Report Facts
Capacity: 185
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kasie Wimmer | Administrator | Applicant/administrator who participated in COMP II and was interviewed |
| David Coluzzi | Corporate Board member | Participant in COMP II |
| Darla Neeley | Licensing Program Manager | Named in report signature section |
| Katie Keith | Licensing Program Analyst | Named in report signature section |
Loading inspection reports...
