Inspection Reports for Carlton Senior Living Sacramento

An unannounced annual inspection was conducted to evaluate compliance with licensing requirements at Carlton Senior Living Sacramento.

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.

An unannounced complaint investigation visit was conducted in response to allegations that staff were not meeting a resident's care needs.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

The visit was an unannounced post-licensing inspection conducted to fulfill the required 1-year visit for facility licensing compliance.

The inspection found no deficiencies. The facility met all regulatory requirements including safety, medication storage, emergency preparedness, and environmental conditions.

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.

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 was investigated and deemed unfounded. The allegations were dismissed as false or without reasonable basis.

The inspection visit was an unannounced complaint investigation triggered by an allegation that facility staff sexually abused a resident in care.

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.

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.

Unannounced required 1 year annual inspection visit to evaluate the facility's compliance with health and safety regulations and licensing requirements.

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.

An unannounced Case Management visit was conducted to address concerns regarding a resident's elopement on 7/23/2023.

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.

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.

Unannounced prelicensing visit conducted to evaluate the facility for licensing purposes.

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.

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.

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.