Deficiencies (last 5 years)
Deficiencies (over 5 years)
2.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
35% better than California average
California average: 4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
77% occupied
Based on a March 2026 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 143
Capacity: 185
Deficiencies: 1
Date: Mar 4, 2026
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff did not treat a resident with dignity and respect, specifically that staff yelled at a resident.
Complaint Details
The complaint was substantiated regarding staff not treating the resident with dignity and respect, but unsubstantiated regarding staff yelling at the resident. The investigation included interviews, video footage review, and collateral interviews. Staff 3 was terminated and the facility conducted mandatory staff training on personal rights and dementia care.
Findings
The investigation substantiated that Staff 3 did not treat Resident 1 with dignity and respect by calling the resident 'stupid' in a frustrated tone. However, the allegation that staff yelled at the resident was unsubstantiated due to insufficient evidence. The facility took corrective actions including staff training and termination of Staff 3.
Deficiencies (1)
Staff 3 did not treat Resident 1 with dignity and respect, calling the resident 'stupid' and failing to use proper redirection techniques.
Report Facts
Facility capacity: 185
Census: 143
Deficiency count: 1
Plan of Correction due date: Mar 5, 2026
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kasie Wimmer | Administrator | Met with Licensing Program Analyst during investigation and provided statements |
| Rose De La Garza | Director of Memory Care | Met with Licensing Program Analyst during investigation |
| Cynthia Tamayo | Licensing Program Analyst | Conducted the complaint investigation |
| Staff 3 | Staff member found to have not treated resident with dignity and respect and subsequently terminated |
Inspection Report
Complaint Investigation
Capacity: 185
Deficiencies: 0
Date: Jan 22, 2026
Visit Reason
The inspection was conducted as an unannounced complaint investigation following a complaint received on 2025-09-30 regarding the sanitary condition of placemats used for meal services.
Complaint Details
The complaint alleged that staff do not ensure that placemats used for meal services are kept in a sanitary condition. The investigation found no conclusive evidence to substantiate the allegation, resulting in an unsubstantiated finding.
Findings
The Licensing Program Analyst observed general cleanliness during dinner service and found no recent history of uncleanliness reported by clients. Although some kitchen staff expressed concerns about placemat drying, the kitchen manager stated placemats are chemically treated and pest control is contracted. The allegation was unsubstantiated due to lack of preponderance of evidence.
Report Facts
Facility capacity: 185
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Noel Wolf Petersen | Licensing Program Analyst | Conducted the complaint investigation |
| Kasie Wimmer | Administrator | Facility administrator named in the report |
Inspection Report
Annual Inspection
Census: 7
Capacity: 185
Deficiencies: 0
Date: 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 safety, and staff background clearances. No deficiencies were observed or cited during the visit.
Report Facts
Residents observed during inspection: 7
Hot water temperature: 117.9
Call alert response time: 142
Call alert response time: 137
Food inventory duration: 7
Food inventory duration: 2
Facility capacity: 185
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kasie Wimmer | Designated Facility Administrator / Executive Director | Named as the facility administrator who was unavailable for interview |
| Cal Mendiola | Designee | Met with Licensing Program Analyst during inspection and exit interview |
| Kimberly Viarella | Licensing Program Analyst | Conducted the inspection |
| Stephen Richardson | Licensing Program Manager | Named in report header and signature |
Inspection Report
Annual Inspection
Census: 7
Capacity: 185
Deficiencies: 0
Date: 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: 131
Capacity: 185
Deficiencies: 2
Date: Jul 7, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted to deliver findings related to multiple allegations including inadequate pest control, failure to provide bathing services, and unsanitary resident rooms.
Complaint Details
The complaint investigation was substantiated for allegations of inadequate pest control, failure to provide bathing services, and unsanitary resident room conditions. The allegations regarding clean linens and personal rights violations were unsubstantiated.
Findings
The investigation substantiated that the facility failed to adequately treat for pests, did not ensure a resident was provided bathing services, and did not maintain a resident's room in clean sanitary conditions. Two other allegations regarding clean linens and personal rights violations were found unsubstantiated.
Deficiencies (2)
Facility did not ensure that the residents room was kept in a clean and sanitary manner; pest control services were inadequate.
Licensee did not ensure that resident R1 was provided showering services as required.
Report Facts
Capacity: 185
Census: 131
Deficiencies cited: 2
Plan of Correction Due Date: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Arielle Pascua | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Kasie Wimmer | Administrator | Facility administrator named in the report |
| Rose Dela Garza | Facility Designated Representative (FDR) | Met with Licensing Program Analysts during the investigation |
Inspection Report
Complaint Investigation
Census: 142
Capacity: 185
Deficiencies: 1
Date: 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 personal rights concerns.
Complaint Details
The visit was complaint-related, investigating an incident where R2 was found in R1's room, with R1 non-ambulatory and partially undressed. The complaint was substantiated as a personal rights violation.
Findings
The facility was found to have violated personal rights regulations when resident R1 was found in a compromising situation with resident R2, who has a history of aggressive behavior. The facility failed to ensure proper supervision to keep the residents separated, posing an immediate risk to residents' health, safety, and personal rights.
Deficiencies (1)
Residents in all residential care facilities shall have personal rights including dignity in personal relationships. The licensee did not ensure this requirement was enforced, violating R1's personal rights.
Report Facts
Capacity: 185
Census: 142
Deficiency count: 1
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 in the report as Licensing Program Manager |
| Cal Mendilola | Designated Facility Administrator/Executive Director interviewed during the visit |
Inspection Report
Complaint Investigation
Census: 142
Capacity: 185
Deficiencies: 2
Date: May 22, 2025
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that staff were not meeting residents' care needs.
Complaint Details
The complaint alleged that staff were not meeting residents' care needs. The allegation was substantiated based on evidence including care notes, interviews, and records review.
Findings
The investigation found that resident R1 was not receiving necessary incontinent care, had multiple falls without an updated strategic fall prevention plan, and care plans were not adequately updated to reflect changes in resident needs. The allegation was substantiated.
Deficiencies (2)
Failure to ensure incontinent residents are kept clean and dry as required by regulation.
Failure to ensure corresponding changes are made in care and supervision following reappraisals, including lack of a strategic fall prevention plan.
Report Facts
Resident weight gain: 18
Falls: 5
Census: 142
Total Capacity: 185
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Viarella | Licensing Program Analyst | Conducted the complaint investigation visit. |
| Stephen Richardson | Supervisor | Supervisor overseeing the investigation. |
| Cal Mendiola | Facility representative met during the investigation. | |
| Kasie Wimmer | Administrator | Facility administrator named in the report. |
Inspection Report
Complaint Investigation
Census: 142
Capacity: 185
Deficiencies: 2
Date: 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.
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.
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.
Deficiencies (2)
Failure to ensure incontinent residents are kept clean and dry as required by CCR 87625(b)(3).
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).
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
Date: 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.
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.
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.
Deficiencies (1)
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.
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
Census: 185
Capacity: 185
Deficiencies: 1
Date: Jan 23, 2025
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 2024-06-24 regarding resident safety and supervision concerns at Carlton Senior Living Sacramento.
Complaint Details
The complaint investigation was substantiated. The resident (R1) sustained multiple falls, including a fatal fall on 2024-05-29. The facility failed to provide adequate supervision and did not update care plans or increase monitoring after prior falls. A civil penalty of $500 was assessed due to injury resulting from these violations.
Findings
The investigation found that a resident (R1), identified as a fall risk, sustained multiple falls including a fatal fall on 2024-05-29 due to inadequate supervision and failure to implement effective fall prevention strategies. The facility did not update the Individual Service Plan appropriately or increase supervision after prior falls, leading to a substantiated violation and a civil penalty.
Deficiencies (1)
The licensee did not ensure the resident's needs were met as evidenced by failure to mitigate fall risks and provide adequate supervision.
Report Facts
Capacity: 185
Census: 185
Civil penalty amount: 500
Number of falls by resident R1: 5
Plan of Correction Due Date: Jan 24, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kasie Wimmer | Administrator | Facility administrator interviewed and present during exit interview |
| Kimberly Viarella | Licensing Program Analyst | Evaluator who conducted the complaint investigation |
| Stephen Richardson | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Capacity: 185
Deficiencies: 1
Date: 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.
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.
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.
Deficiencies (1)
The licensee did not ensure resident needs were met as evidenced by failure to mitigate fall risks and provide adequate supervision.
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
Date: Sep 17, 2024
Visit Reason
Licensing Program Analyst Victoria Brown conducted an unannounced Required - 1 Year visit to evaluate the facility's compliance with licensing regulations.
Findings
The facility was inspected for safety hazards, emergency preparedness, and compliance with regulatory requirements. No deficiencies were cited during this visit, and all required documentation and safety measures were found to be in place.
Report Facts
Residents receiving hospice care: 8
Non-ambulatory residents allowed: 120
Hospice care residents allowed: 20
Temperature thermostat: 75
Hot water temperature: 114.2
Emergency drill date: Aug 29, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kasie Wimmer | Administrator/Director | Met with Licensing Program Analyst during inspection |
| Victoria Brown | Licensing Program Analyst | Conducted the inspection visit |
| Stephen Richardson | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Annual Inspection
Census: 150
Capacity: 185
Deficiencies: 0
Date: 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
Date: 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
Date: Sep 10, 2024
Visit Reason
An unannounced complaint investigation was conducted following 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.
Complaint Details
The complaint was investigated and found to be unfounded. The allegations were dismissed as false or without reasonable basis.
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.
Report Facts
Capacity: 185
Census: 153
Estimated Days of Completion: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kasie Wimmer | Executive Director/Administrator | Interviewed during the complaint investigation |
| Victoria Brown | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 153
Capacity: 185
Deficiencies: 0
Date: 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.
Complaint Details
Complaint was investigated and deemed unfounded. The allegations were dismissed as false or without reasonable basis.
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.
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
Date: Jun 20, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that facility staff sexually abused a resident in care.
Complaint Details
The complaint alleged that facility staff sexually abused a resident in care. The allegation was unsubstantiated after investigation.
Findings
The investigation included interviews with the resident and witnesses, and a review of facility documentation. It was determined that the resident was unable to identify a suspect, and the information did not result in a credible source to substantiate the allegation. The allegation was found to be unsubstantiated.
Report Facts
Capacity: 185
Census: 142
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Bilger | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Kasie Wimmer | Administrator | Facility administrator met during the investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 142
Capacity: 185
Deficiencies: 0
Date: 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.
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.
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.
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
Date: Sep 6, 2023
Visit Reason
Licensing Program Analyst Ruth Wallace conducted an unannounced required 1 year annual inspection visit to evaluate the facility's compliance with health and safety regulations.
Findings
The facility was observed to be clean, odor-free, and in good repair with all required furniture and safety features present. No deficiencies were cited during the inspection, and all staff and resident files were complete with proper clearances.
Report Facts
Water temperature: 110.7
Fire extinguisher inspection date: Jan 1, 2023
Staff files reviewed: 6
Resident files reviewed: 5
Hospice waiver capacity: 20
Residents receiving home health services: 8
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 inspection visit |
| Stephen Richardson | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Annual Inspection
Census: 135
Capacity: 185
Deficiencies: 0
Date: 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
Date: Jul 26, 2023
Visit Reason
An unannounced Case Management visit was conducted to address concerns regarding a resident's elopement on 7/23/23.
Complaint Details
The visit was complaint-related due to a resident's elopement incident on 7/23/23. The resident was identified as unable to leave unassisted by his physician. The complaint was substantiated by the findings.
Findings
Resident R1, who was determined unable to leave the facility unassisted, eloped through the rear gate without staff knowledge. Staff mistakenly reset the delayed egress alarm, allowing the elopement. The resident was found without injury. Deficiencies were cited and a civil penalty of $500 was assessed for immediate violations.
Deficiencies (1)
Care of Persons with Dementia: Facility staff failed to attempt to redirect a resident who attempted to leave the facility, violating Personal Rights.
Report Facts
Civil penalty amount: 500
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kasie Wimmer | Administrator | Met with Licensing Program Analyst during the visit |
| Tung Truong | Licensing Program Analyst | Conducted the unannounced Case Management visit |
| Czarrina A Camilon-Lee | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 146
Capacity: 185
Deficiencies: 1
Date: Jul 26, 2023
Visit Reason
An unannounced Case Management visit was conducted to address concerns regarding a resident's elopement on 7/23/2023.
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.
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.
Deficiencies (1)
Care of Persons with Dementia: Facility staff failed to redirect a resident who attempted to leave the facility, violating Personal Rights under Section 87468.
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
Date: 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
Date: 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 |
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