Karlton Residential Care Center

Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced visit to the facility to deliver findings regarding the above-mentioned allegation. Upon arrival, LPA was greeted and granted entry by AD Weiner Elena . The investigation revealed that Resident (R1) was admitted to the facility on May 18, 2023. The Physician’s Report dated May 17, 2023, documented diagnoses of seizures, epilepsy, and dementia, and indicated R1 was non-ambulatory, required full assistance with all Activities of Daily Living (ADLs), and had generalized weakness. R1 was admitted under hospice care through Vitas Hospice of Orange County with terminal diagnoses of cerebrovascular disease and hypothyroidism. Hospice records indicated that R1 was completely dependent for all ADLs, incontinent of bowel and bladder, and identified as a high fall risk due to agitation and confusion. {***CONTINUE***9099C1} SubstantiatedRead the full finding— CDSS inspection report, December 16, 2025 · control 22-AS-20250417112836

Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit to the facility to conclude investigation into the above identified complaint allegation. LPA arrived at the facility and was greeted at the door and granted entry. LPA spoke with Elena Weiner, Administrator, and explained the purpose of the visit. Findings are based upon this investigation which included tour of the facility, resident file review, and interviews conducted. It is alleged that lack of supervision resulting in resident sustaining multiple falls. Records review revealed that resident (R1) was admitted to the facility on January 26, 2024, with a diagnosis of Congestive Heart Failure and no history of falls. Appraisal needs and services plan was completed on January 26, 2024, Continued on LIC9099-C UnsubstantiatedRead the full finding— CDSS inspection report, November 6, 2025 · control 22-AS-20240506110111

Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit to the facility to conclude investigation into the above identified complaint allegation. LPA arrived at the facility and was greeted at the door and granted entry. LPA spoke with Elena Weiner, Administrator and explained the purpose of the visit. Findings are based upon this investigation which included tour of the facility, resident file review, and interviews conducted. It is alleged that resident sustained pressure injury while in care. Interview with staff stated that resident (R1) was sent out to the hospital on August 31, 2024, and returned the same day with home health referral. Record review revealed that R1 was sent to hospital on August 31, 2024, for left foot pain and Continued on LIC9099-C UnsubstantiatedRead the full finding— CDSS inspection report, November 6, 2025 · control 22-AS-20241007132932

Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit to the facility to conclude investigation into the above identified complaint allegation. LPA arrived at the facility and was greeted at the door and granted entry. LPA spoke with Elena Weiner, Administrator and explained the purpose of the visit. Findings are based upon this investigation which included tour of the facility, resident file review, and interviews conducted. It is alleged that facility did not ensure that resident was kept clean and dry. Interview with staff stated that resident (R1) was never left in soiled diapers and when R1 calls for a diaper change they change them even if it’s every five minutes. Interview with R1 stated that staff change their diaper as needed. Continued on LIC9099-C UnsubstantiatedRead the full finding— CDSS inspection report, November 6, 2025 · control 22-AS-20241113114841

On 05/23/2025, Licensing Program Analyst (LPA) Cassandra Mikkelson contacted the licensee via phone and email to deliver final findings regarding a complaint that was received on 08/05/2024. **Report continued on 9099- C page** Unsubstantiated— CDSS inspection report, May 23, 2025 · control 22-AS-20240805115109

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on the investigation of the two allegations listed above. LPA was greeted and granted entry by facility staff after explaining the purpose of the visit. Administrator Elena Weiner was present on the premises and assisted with the visit. An initial complaint investigation visit was held on February 13, 2024. LPA accompanied by administrator conducted a tour of the facility's physical plant including a dedicated unit currently in place after a total of 18 residents tested positive for COVID starting on or around February 5th, 2024. LPA reviewed resident clipboards maintained for residents flagged with risks of skin breakdown due to the use of incontinence supplies and was provided a list of residents being provided with incontinence supplies. CONTINUED ON FORM LIC9099-C UnsubstantiatedRead the full finding— CDSS inspection report, May 6, 2024 · control 22-AS-20240209141147

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegation. LPA met with Administrator (AD) Elena Weiner and explained the reason for today’s inspection. The investigation into the allegation of Lack of supervision resulting in multiple falls revealed the following: During the course of the investigation, LPA inspected the facility, interviewed AD, staff, residents, and witnesses, and requested and reviewed copies of the resident roster, staff roster, Resident #1’s (R1) Resident Appraisal (LIC603A) dated 12/31/19, R1’s Appraisal/Needs and Services Plan (LIC625) dated 01/03/20, R1’s Physician’s Reports (LIC602A) dated 12/31/19, 09/15/20, 02/21/22, and 06/22, Unusual Incident/Injury Reports (LIC624) dated 07/04/22 and 08/03/22, and R1’s Medical Records dated 12/01/22 and 11/22/22. It was reported that on 11/22/22 R1 had a fall at the facility andRead the full finding— CDSS inspection report, December 12, 2022 · control 22-AS-20221123123607

Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry by Administrator Elena Weiner and explained the reason for the visit. During the course of the investigation, LPA toured the facility, interviewed staff and witnesses as well as reviewed and obtained pertinent documentation such as hospital discharge paperwork. Regarding the allegation that staff did not prevent multiple falls from resident's wheelchair, the investigation revealed the following: Resident 1 (R1) was seen in the emergency room on 06/30/2022 for a closed head injury after falling out of the resident's wheelchair. Facility staff indicate the resident passed out in the wheelchair and fell forward. On 07/07/2022, R1 was sent out for lethargy and not eating. R1 was determined to be septic and had an endoscopy to determine gallstones and common bile duct issues. Resident would subsequently have common bile duct surgerRead the full finding— CDSS inspection report, October 13, 2022 · control 22-AS-20220729170339

Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry by Administrator Elena Weiner and explained the reason for the visit. During the course of the investigation, LPA toured the facility, interviewed staff and witness as well as reviewed and obtained pertinent information such as facility billing invoice. Regarding the allegation that facility did not issue refund, the investigation revealed the following: Resident 1 (R1) resided at the facility from 06/08/2022 through 6/17/2022. Resident was sent out to the hospital on 06/17/2022 and family moved resident out of the facility without a written thirty day notice. Per health and safety code, a refund of 80 percent of the preadmission fee, minus $500, is due back if resident moves out within the first month. Facility did not refund any money to the resident's responsible party. Based on observations made and interviews conducted, tRead the full finding— CDSS inspection report, October 3, 2022 · control 22-AS-20220902113459

Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry by Administrator Elena Weiner and explained the reason for the visit. Licensee Barbara Weiner was present as well. During the course of the investigation, LPA Jim August interviewed facility staff. LPA Lyman toured the facility, reviewed pertinent documentation such as staff schedule and shower schedule and interviewed Administrator and Licensee. Regarding the allegation that inadequate staffing resulting in resident's showering needs not being met, the investigation revealed the following: Interview conducted as well as review of facility schedules indicates facility utilizes the following for staff: 6 caregivers on the first shift along with LVN, 5-6 caregivers on second shift, and 2 caregivers on the NOC shift. Administrator indicates staff will stay over if there is a call out and interview with Licensee indicates facilityRead the full finding— CDSS inspection report, August 2, 2022 · control 22-AS-20210701083224

Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry by Administrator Elena Weiner and explained the reason for the visit. Licensee Barbara Weiner was present as well. During the course of the investigation, LPA August interviewed Administrator Weiner as well as reviewed and obtained pertinent documentation such as physician report and hospital paperwork. Regarding the allegation that resident sustained multiple falls while in care, the investigation revealed the following: On June 23, 2021, Resident 1 (R1) was exhibiting confusion, poor gait, loss of appetite and loss of balance. R1 was experiencing insomnia as well. R1 was noted to have no injuries and a urinalysis was performed. R1's physician was contacted and follow up was scheduled. Facility utilized a bed alarm for resident. On June 24, 2021, R1 was exhibiting more confusion and lost balance on the edge of the bed. R1 wasRead the full finding— CDSS inspection report, August 2, 2022 · control 22-AS-20210629113400

Licensing Program Analysts (LPAs) Kimberly Lyman and Joseph Alejandre conducted an unannounced complaint visit to deliver findings on the above allegations. LPA was greeted and granted entry into the facility by Administrator Elena Weiner and explained the reason for the visit. During the course of the investigation, the Department interviewed staff and witnesses as well as reviewed and obtained pertinent documentation such as physician report dated 08/23/2021, medication orders and Los Alamitos Medical Center admission paperwork dated 10/04/2021. Regarding the allegations that resident sustained unexplained bruising while in care and resident’s diapering needs were not being met, the investigation revealed the following: Resident 1 (R1) was sent to Los Alamitos Hospital on 10/04/2021 for repeated abdominal pain. While there, it was observed the resident had unusual bruising and a soiled diaper. Per an interview conducted with the facility Administrator, R1 had been at Los Alamitos HosRead the full finding— CDSS inspection report, May 4, 2022 · control 22-AS-20211004170327

Licensing Program Analysts (LPAs) Kimberly Lyman and Joseph Alejandre conducted an unannounced complaint visit to deliver findings on the above allegation. LPAs were greeted and granted entry into the facility by Administrator Elena Weiner and explained the reason for the visit. During the course of the investigation, the Department interviewed staff and witnesses as well as reviewed and obtained pertinent documentation such as physician report dated 07/19/2021 and medical records dated 10/23/2021-10/29/2021. Regarding the allegation that resident sustained unexplained injury while in care, the investigation revealed the following: On 10/12/2021, Resident 1 (R1) was hospitalized at Chapman Global Medical Center for psychiatric treatment and self-injurious behavior. Upon return to the facility on 10/29/2021, R1 was observed to have visible bruises on legs, arms and right side of lip. R1 returned to Chapman Global Medical Center on 11/06/2021 for confusion and lack of sleep. Upon admissiRead the full finding— CDSS inspection report, May 4, 2022 · control 22-AS-20211109114256