Carlton Senior Living Sacramento Atrium

Type of visit: Required - 1 Year

On August 26, 2026, at 2:00 PM, Licensing Program Analyst (LPA) Sulma Lopez and Licensing Program Manager (LPM) Arielle Pascua arrived unannounced at the facility to conduct an annual required inspection. LPA Lopez and LPM Pascua met with Administrator Kassie Wimmer and explained the purpose of today's visit. The Administrator holds current certificate 7010128740 and expires on May 21, 2027. The facility is approved for 99 non-ambulatory residents ages 60 and over. There is a hospice waiver approved for (15) residents. There are currently 47 residents who reside at this facility. At 2:10 PM, LPA and LPM toured the facility with the administrator. The facility was clean, safe, and in good repair. The facility temperature was 75 degrees. The facility’s hot water temperature was 110 degrees. The facility’s fire extinguishers were last inspected on August 8, 2026. The facility carbon monoxide and fire alarms are located on the ceilings. LPA observed the dining area which was clean and free of hazards. The facility kitchen contained a 7- day supply of non-perishable foods, and at least 2 days of perishable food items. Facility cleaning supplies, toxins, and sharps are stored in the kitchen and made inaccessible to residents. The residents’ bedrooms were clean, free of odors, and contained furniture that was in good repair. The facility contains activity rooms and an activity calendar was posted on the wall. LPA observed residents participating in a game of bingo with staff. Continued on LIC-809C. At 3:00 PM, LPA reviewed (4) staff and (4) resident files. The files are maintained and kept current. The facility has a current Infection Control Plan and Emergency Control Plan which are being reviewed and updated on a regular basis. The facility conducts monthly fire drills and the most recent one took place on August 17, 2026. As a result of today's annual inspection, no deficiencies are being cited. The facility is in compliance with Title 22 regulations. An exit interview was conducted, and a copy of this report was provided to the facilitythe state’s words, verbatim · CDSS document, Aug 26, 2026

Allegation investigated: Staff do not respond to resident's requests for assistance in a timely manner. Staff do not ensure that resident's hygiene needs are met. Staff do not ensure incontinent needs are met.

On 3/27/26, Licensing Program Analyst, LPA, Cynthia Tamayo arrived to the facility unannounced to complete and deliver complaint investigation findings into the above allegation. Upon arrival, LPA met with Senior Executive Assitant, Christin Pannell(S5), and Resident Liaison, Dionne Hamilton (S6), and Care Manager, Kayla Fermil (S7) explained the purpose of the visit. S5 called Director of resident services, Cal Mendiola (S3) via phone and LPA spoke with them via speaker phone as well. Allegation 1: Staff do not respond to resident's requests for assistance in a timely manner. It was alleged “Staff do not respond to resident's requests for assistance in a timely manner”, this investigation focused on Resident 1 (R1). Throughout the process, the LPA conducted facility observationsinterviewed staff and residents, collateral interviews, and reviewed all relevant documents related to R1. S5 stated R1 moved out by their family as of 3/22/26, due to the overall dissatisfaction S2 stated there was an incident in which around 3:20 PM on 2/22/26, Resident 1’s (R1’s) family came for visit R1 and they reported the room was not cleaned and R1 was wet and needed to be changed. [CONTINUED ON 9099-C1] Substantiated S2 stated that R1's room was cleaned right away by staff once the family addressed the concern and an internal investigation was conducted. The investigation found that Care partner, Staff 4 (S4), in the morning did not meet expectations of cleaning R1 and R1's room. S2 stated they were in a rush and neglected to complete cleaning for R1. As a result, R4 received corrective action and where removed from the schedule pending additional training. On 3/4/26, LPA observed R1 pressed their call button and a care partner arrived to their room within one minute. S2 stated that the ideal response time is 5 minutes but it is “ideally” expected to be no more than 3-10 minutes. Additionally, it was reported that on 3/4/26 at around 3:00 AM, R1 had back pain and they pressed their call button to request a Tylenol (PRN) medication for pain. Staff responded to the call and repositioned them in bed but did not return to give R1 the requested pain medication. S2 stated the missed medication was due to a staff feeling unwell and they went off shift without passing along the information to ensure R1 received the requested PRN medication. Record review and Staff interviews confirm R1 was paying extra for medication management as the services are provided are a la cart. It was reported the facility is not requesting medication in time which may results in R1 missing medication doses on several occasions including 3/5/26 . On 3/9/26, the facility informing contacted R1's family to inform that R1 ran out of cholesterol/blood pressure medications. Record review of R1’s care plan indicated they receive Medication management is “Level 3 (11-20 medications)” and they receive medication management services. Medication and Reporting Requirement guidance was provided to S1 and S2. S2 stated medication was missed due to prescription being expired and they missed due to pharmacy delays March 2026. It was reported that R1 was paying for the extra service to “be walked” and taken to activities but the service was removed since staff not taking R1 on walks or to activities timely or at all. Staff stated "escort services" were provided and there was not a known discrepancy with this service. Additionally, S2 reported on December 8th 2025, there was a complaint reported to the facility by R1's family member (RP), in which R1 reported that care partners were not answering their calls. S2 and S6 corroborate that all of R1's calls were not being answered timely. On December 5th 2025, RP stated she called the community at approximately 1:45pm to request that the resident was dressed and ready for an outing by 4pm. S2 stated the family reported R1's brief was soiled upon arrival and they were not ready by the time requested . Dress Assist services were not met. S6 stated long wait times did occur of up to an hour or no response at all due to previous management and short staffing. Based on interviews and record review, “Staff do not respond to resident's requests for assistance in a timely manner”, is substantiated. CONTINUED ON 9099-C3 Allegation 2: Staff do not ensure that resident's hygiene needs are met. It was alleged “Staff do not ensure that resident's hygiene needs are met”, this investigation focused on Resident 1. Throughout the process, the LPA conducted facility observations, interviewed staff and residents, collateral interviews, and reviewed all relevant documents related to R1.S2 and S5 reported R1 was moved out of the facility as of 3/22/26 due to overall dissatisfaction. Staff corroborated reports that incontinent and hygiene needs were not met for R1. On 3/4/26, S2 stated that at around 3:20 PM on 2/22/26 Resident 1’s (R1’s) family came for visit R1 and they reported the room was dirty and R1 was wet and needed to be changed. The apartments was cleaned right away by staff and an internal investigation was conducted and it was found that Care partner, Staff 4 (S4), did not meet expectations of cleaning R1 and cleaning R1's room. S2 stated S4 reported they were in a rush and neglected to complete cleaning for R1. As a result, R4 received corrective action and where removed from the schedule pending additional training. Additionally, on 2/24/26, a corrective action write up was given to Care Manger , Tonya Nepali (S3), whom was supposed to train all care staff, including S4. S2 stated S3 was terminated. S2 stated, that on 2/26/26, he apartment was not ”up to standard” as it was not cleaned; the room trash bin was not emptied out, and R1's Purewik device was not cleaned out. R1 uses an external catheter at night time and the facility is supposed to clean it every morning. Staff, R1, and collateral persons interviewed stated showers and bathing are done once per week as stated on their service plan. On 3/4/26, LPA observed R1 and R1’s room was clean and free of odors. LPA was unable to confirm if R1’s wheelchair seat smelled of urine. S6 stated long wait times did occur of up to an hour or no response at all due to previous management (S3) and short staffing. Based on interviews and record review of the allegation “Staff do not ensure that resident's hygiene needs are met”, is substantiated. [CONTINUED ON 9099-C4] Allegation 3: Staff do not ensure incontinent needs are met. It was alleged “Staff do not ensure incontinent needs are met”, this investigation focused on Resident 1 (R1). Throughout the process, the LPA conducted facility observations, interviewed staff, residents, collateral interviews, and reviewed relevant documents related to R1. S2 and S5 reported R1 was moved out by their family as of 3/22/26 due to overall dissatisfaction. Record review shows R1’s primary diagnosis is Dementia. R1’s “Assisted living assessment” was completed on 06/12/2025 for R1. R1’s Service Plan lists “Continence Care” in which “Resident will be offered assistance with toileting … Continence Care - 60 min/day … Staff will offer approximately 60 minutes of assistance per day while the resident uses the bathroom”. It is indicated that this is the responsibility of the Care Partner. Also, the plan details that the Care Partner “staff to be aware of resident's unique toileting needs. Indicate in notes … Purewick use during overnight”. Medication management is “Level 3 (11-20 medications)”. The “Residence and Service Agreement” state the following: “The appraisals described above and, in this Agreement, including those conducted at the time of admission and thereafter during your residency at The Community, are considered by us in determining, setting and monitoring staffing levels at The Community. We consider the appraisal and other factors to determine, set, or monitor staffing levels at The Community”. The plan recommended the following additional services for R1: Continence Care -Monthly $ 995.00 / Monthly, Dress Assist 2 -Monthly $ 1000.00 / Monthly, Emergency Pendant -Monthly $ 55.00 / Monthly, Escort Assist -Monthly $ 700.00 / Monthly, Get Ready Assist -Monthly $ 340.00 / Monthly, Med Mgmt 2 - External Pharmacy -Monthly $ 1100.00 / Monthly, Shower Assist 1 -Monthly $ 250.00 / Monthly. S2 stated that at around 3:20 PM on 2/22/26 Resident 1’s (R1’s) family came for visit R1 and they reported the room was not cleaned and R1 was wet and needed to be changed. The apartments was cleaned right away by staff and an internal investigation was conducted and it was found that Care partner, Staff 4 (S4), in the morning did not meet expectations of cleaning R1 and R1's room. S2 stated they were in a rush and neglected to complete cleaning for R1. As a result, R4 received corrective action and where removed from the schedule pending additional training. Additionally, on 2/24/26, a corrective action write up was given to Care Manger , Tonya Nepali (S3), whom was supposed to train all care staff, including S4, S3 was terminated. S2 stated, the apartment was not ”up to standard” as it was not cleaned; the room trash was not cleaned , and R1's Purewik device was not cleaned out. R1 uses an external catheter at night time and the facility is supposed to clean daily. [CONTINUED ON 9099-5] Although a plan of correction was put in place prior in March 2026, it was reported that on 3/8/26 R1’s purewik external catheter was observed to not emptied out and cleaned until after 2:00PM on that day. S6 stated long wait times did occur of up to an hour or no response at all. It is possible that R1 was left sitting for hours in soaked and soiled briefs. It was alleged that a care staff advice whom no longer works at the facility would advise “doubling up” in which two diapers were used for R1, this would result in R1 getting irritations and pressure injuries. Staff are unaware of any staff advising to "double up". S1, S5, and S6 stated R1 preferred double padding and it was accommodated as it was the residents' preference but there was no "double briefing" as it is not allowed. Based on interviews and record reviews the allegation "Staff do not ensure incontinent needs are met" is substantiated. S5 stated that an interval investigation determined that Former Care Manger (S3) did not ensure to sufficient oversight over care staff. S7 (S7) was hired as of March 2026 as the new Care Manager in charge of oversight of care staff. Since starting, S7 is ensuring care staff calls button requesters are processed are responded to more thoroughly and that the facility is fully staffed and trained. In service training thus far include "Speak 2 Pendant Response" held on 3/21/26 and 3/25/26. Previously staff was able to clear calls before being with the residents, however the updated training requires staff is physically with the resident before a call can be cleared and ensuing accuracy of meeting resident needs by implementation of online charting system, Yardi. Yardi, allows staff to chart after each service is completed by staff such as continence care, showers, meal assistance, escort service, etc. The charting system was in place before but was not being used by the former Care Manger, S3. S2 stated S7 was fired due to not enuring sufficient oversight over care staff. As 3/11/26, facility has implemented shift cross over meetings for all shift changes, As a result, the allegations above are SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. Guidance on reporting requirements were provided. An exit interview was conducted with S7 and S5 and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided.the state’s words, verbatim · CDSS document, Mar 27, 2026 · control 27-AS-20260226143817

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: Mar 30, 2026

87625 Managed Incontinence(b) In addition to Section 87611, General Requirements for Allowable Health Conditions .. (3)Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met as evidenced by record review, interviews with staff, resident, and collateral interview, in which it was corroborated Staff do not ensure incontinent needs for Resident 1 (R1) were being met at all times. This poses an immediate or potential health concern for residents' in care.the state’s words, verbatim · CDSS document, Mar 27, 2026

Plan of correction: Staff stated that as of 3/11/26, the facility has begun to implement shift change cross over meetings for all shift changes, as well as to ensure charting system, Yardi, is being used daily by staff. S7 In service training on incontinent care will be held for staff. POC verification will be faxed or emailed to the Regional Office by POC due date

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Mar 30, 2026

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities ... shall have all ... personal rights ... (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met, as evidence by interviews with staff, residents, and collateral interviews corroborating staff did not respond to resident 1 (R1's) requests for assistance in a timely manner. This poses an immediate or potential health concern for residents' in carethe state’s words, verbatim · CDSS document, Mar 27, 2026

Plan of correction: Since 3/11/26, the facility has begun to implement shift change cross over meetings for all shift changes, as well as to ensure charting system, Yardi, is being used daily by staff. S7 stated training regarding personal rights was conducted on 3/25/26. POC verification will be faxed or emailed to the Regional Office by POC due date

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(d) · Plan of correction due date: Mar 30, 2026

87464 Basic Services (d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified ... This requirement was not met as evidenced by record review and interviews with staff, resident, and collateral interview, in which it was corroborated that staff did not ensure that resident's hygiene needs were met for Resident 1 (R1). This poses an immediate or potential health concern for residents' in carethe state’s words, verbatim · CDSS document, Mar 27, 2026

Plan of correction: Staff reported that as of 3/11/26, the facility has begun to implement shift change cross over meetings for all shift changes, as well as to ensure charting system, Yardi, is being used daily by staff. S7 stated in service training will be held for staff. The POC verification will be faxed or emailed to the Regional Office by POC due date.

Allegation investigated: Staff are not following resident's individual service plans Staff do not ensure that resident needs are met Staff are falsifying resident records

On 9/19/25 at 4am, Licensing Program Analyst,LPA, Noel Wolf Petersen arrived unannounced to conduct a complaint investigation into the above allegations. LPA met with staff Kal Mendiola by phone to explain the purpose of the visit, and then later with Kasie Wimmer by phone. LPA conducted physical inspection of the grounds, interviewed several of the staff, asked to review documents: lic500, lic9020, recent hospitializations, shift logs. LPA observed clients being attended to in a timely fashion, staff responding to calls as needed. No falseificaiton of records were observed. amongst Staff and clients interviewed, there was some conflicting fingerpointing and hearsay regarding the allegations, but nothing resolvable. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, no citations were issued. a copy of the report was read and given to staff. Unsubstantiatedthe state’s words, verbatim · CDSS document, Sep 19, 2025 · control 27-AS-20250624133508

Allegation investigated: Staff required resident's authorized representative to sign admission documents that interfered with resident's personal rights

On 8/22/25 at 8:45am, Licensing Program Analyst(LPA) Noel Wolf Petersen and Licensing Program Manager (LPM) Liza King arrived to conduct a complaint investigation, LPA and LPM met with executive director Kasie Wimmer to explain the purpose of the visit. The above allegation was investigated by Record review. The Admission agreement appendix Ahas a clause number 11 that states in paraphrase, that the arbitration agreement segment is volluntary and not a condition of admission or care to the facility. LPA gave the guidance that the volluntary element should be more promenently displayed, but it is not out of compliance. This agency has investigated the complaint and found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/ or is without a reasonable basis.” An exit interview was conducted, the report was read a copy of the report and appeal rights was given to the Executive Director. Unfoundedthe state’s words, verbatim · CDSS document, Aug 22, 2025 · control 27-AS-20250509144019

Type of visit: Required - 1 Year

Licensing Program Manger (LPM) Liza King and Licensing Program Analysts (LPA) Noel Wolf Petersen arrived at this facility unannounced to conduct a Required 1 Year Annual Inspection Visit. LPm was met by Executive Ast and administrator joined 30 minutes later. LPM explained the purpose of the visit to Administrator and Executive Ast. Facility currently has 6 residents receiving home health, 7 residents on hospice, 5 residents use a hoyer lift. Staffing on average is Am shift 2 MedTechs(MT) and 7 caregivers (CG) PM shift 5 CG and 1 MT and overnight shift 3CG and 1MT. LPM and Executive Ast inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry area, living area and other common areas, as well as outside of the facility to ensure compliance with Title 22 regulations. Throughout the day LPM and LPA observed breakfast and lunch service, exercise program, neighborhood walking groups, bingo and painting and fresh popcorn service. Chemicals and medications noted to be locked to residents in care. Residents rooms did contain various personal care products and cleaning supplies which could pose a risk to those clients that wander throughout the facility. No bodies of water were observed at the facility. cont. Hot water temperature was measured at 107 F degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees Fahrenheit. All necessary documents were in place. LPM observed the all necessary posters on the facility wall: incl but not limited to Facility license, See Something Say Something poster, Ombudsman poster, Rights of Resident/Family Councils. LPM reviewed 7 resident files (3 of which were on hospice) all medical assessments and care plans appear to be up to date. Additional documentation reviewed included Hospice documentation and daily notes, Centrally Stored medications lists, MARS, and admissions required documents. R6 during the month of July 2025 went without a medication for heart failure for 3 consecutive days and during Aug 2025 the resident went without the same medication for 8 consecutive days and counting. A discussion occured and an explanation was provided that the medication is not covered by the resdients current medical provider, no alternative means have been identified. A Citation will be issued. The facility has recently changed to a new EHR system. LPM toured the facility during breakfast service and again in the afternoon to observe repairs that have been made. During the morning tour, LPM observed: A tour of the kitchen revealed unlabeled foods in the Refrigerator, freezer and pantry. The seal on the door of the freezer was not working properly causing food to be freezer burned and damaged. Additionally a flickering light was obsereved in the hall, multiple screens had holes and the elevator was broken. A repeat tour was conducted and all items were repaired except the flickering light on the hall and screens, technical assistance provided. A citation was issued during todays annual inspoection related to medication administration, an exit interview was conducted with Kasey Wimmer and Appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 22, 2025

Allegation investigated: Medications are not being destroyed as required.

On 05/14/25 Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to open an investigation into the above allegations. LPA identified herself upon arrival, stated the purpose of the visit and asked to meed with the Designated Facility Administrator. LPA met with Executive Assistant Cal Mendiola and a brief interview followed. LPA conducted an inspection of the Wellness Center and the Medication Manager's office. LPA also conducted interviews of 5 staff members. LPA located medications for 3 current residents in the top drawer of the Medication Manager's desk. There were 4 containers present: 3 contained a single pill and the fourth contained a medication cup with and post it note listing the 7 crushed medications. The crushed medications were for a resident who did not take them because they were out of the facility at the time of administration. LPA also located a large bottle of Tylenol for the Medication Manager's personal use. The Medication Manager explained that these resident medications were supposed to be destroyed Substantiated and stated that they had 7 days in which to do so. LPA was told these medications were for 2 residents. One medication was in the appropriate prescription bottle. Another medication was in a medication cup with the resident information hand written on the lid. There were 2 other medication cups without any resident information on them. LPA asked for copies of the Electronic Medication Record (EMAR) for these two residents to see if any notes were included to describe why these medications were in the Medication Manager's possession. The Medication Manager stated that 1 medication crumbled when cut in half and could not be counted or administered. LPA was told that another medication was found on the floor of a resident's room, and the last pill was found in a resident's bedding. There were no notes in the EMAR accounting for these medications or that they were turned into the Medication Manager for destruction. This LPA also learned during the course of this investigation that it was the practice of this facility not to log the destruction of pills found /not taken. Pills were only logged in the centrally stored destruction log if staff found more than one. LPA provided technical assistance regarding the recording and destruction of medications. The standard for the preponderance of evidence was met and the Department found this allegation to be SUBSTANTIATED. According to the California Code of Regulations, Title 22, this deficiency was cited on the LIC 9099D page. A copy of this report was provided along with APPEAL RIGHTS. Exit interview. mean that the allegation is not true or did not happen, it means that there was not enough evidence to substantiate the allegation. According to the California Code of Regulations, no deficiencies were cited during today's visit. A copy of this report along with APPEAL RIGHTS wer provided. Exit interview.the state’s words, verbatim · CDSS document, May 14, 2025 · control 27-AS-20250507202155

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(i) · Plan of correction due date: May 15, 2025

Incidental Medical and Dental Prescription medications which are not taken ..physician and documented in the resident’s record nor disposed of according shall be destroyed ...which lists the following: The Licensee di not ensure the above regulation was enforeced as evidenced by: The LPA observed 4 resident medications in the unlocked desk of the Medication Manager (MM). The MM could not provide documentation explaining why these meds were in their drawer waiting to be destroyed. This posed an immediate risk to the put the health safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, May 14, 2025

Plan of correction: Executive Assisted/Designee stated that he will be submitting a detyailed plan for staff training which will include destruction proceducures, documentation, med passes, developing a new log/procedure for pills found. This will be submittied to CCL by the close of business 05/15/25 by emailing: cclascpsacramentoro@dss.ca.gov

We haven’t transcribed this report yet. The complete document is on the state’s site.

Allegation investigated: Staff mismanaged resident medication Staff did not obtain a hospice care plan for resident Staff did not maintain a comfortable temperature for resident

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conclude the investigation of the above mentioned allegations on 1/15/25 at 8:45am. LPA met with Jose Bernales, Maintenance Manager and stated the purpose of the visit. Administrator Kasie Wimmer arrived within 20 minutes to assist with todays visit. Regarding allegation, "Staff mismanaged resident medication" LPA conducted a review of R1's Physician Report (LIC602) dated 12/26/23 which indicates a prescribed medication called DiazePAM (Valium) 5mg oral tab (1 tab by mouth 1 hr before procedure for 1 dose). LPA observed the Suncrest Hospice Comfort Kit Orders dated 7/18/24 which included morphine 20mg/ml solution 0.5ml (10mg) by mouth/sublingual every hour as needed for pain/shortness of breath. There was also Seroquel (Quetiapine) 50mg tabs ordered for 1 tab in AM and 1.5 tab at bedtime and 1 tab every 4hrs as needed (PRN) and 1 tab now per instructed then it was changed to 2 tabs (100mg) 2 times a day on 7/19/24. Unfounded According to the Suncrest Hospice Sacramento Certification and Plan of Care it indicates that Valium 5mg was prescribed to Resident #1 (R1) on 7/18/24 to take 1 tab orally once a day for muscle spasms which was discontinued on 7/19/24. LPA observed the Medication Administration Record (MAR) for July 2024 and Physician orders which contained changes to medication list. LPA observed that with PRNs the facility documentation has a comment section where staff would input a purpose for the PRN administration. After R1 returned to the facility on the evening of 7/18/24 from the hospital, R1 returned with medication changes. These medications were administered on 7/19/24 by facility staff and on 7/20/24 the Responsible Party was in possession of all R1s medication. In addition, facility conducts medication audits randomly and on every shift the narcotics are counted and logged as well as routine centrally stored medications are counted once received and sometimes randomly. LPA observed the narcotics count log which appears to show medication accounted for and logged. Based on records review and interviews, LPA did not observe a preponderance of evidence standard that facility mismanaged medication for R1. Regarding allegation, "Staff did not obtain a hospice care plan for resident" a review of resident file and hospice records revealed that R1 was admitted to Snowline Hospice on 5/24/24. Per the Case Conference Summary report dated 6/6/24 and 6/20/24 changes were made to the service plan and reassessment of eligibility was conducted. LPA observed that per the Patient Schedule R1 was transferred from Snowline Hospice to Suncrest Hospice on 7/18/24 where there was an initial visit by hospice staff, then 7/19/24 there were 3 follow-up visits, another visit on 7/20/24, and the last visit was conducted on 7/21/24 by a chaplain. Suncrest Hospice Skilled Nursing Visit Notes indicated that R1 Responsible Party gave preference regarding hospitalization and spiritual and all other concerns on 7/18/24. An interview with the Administrator revealed that R1 Responsible Party wanted to change hospice agencies from Snowline to Suncrest and initiated the change after which time the Licensee received the care plan from Suncrest and spoke with the RP regarding implementing the plan. Based on the process of receiving hospice services, traditionally, the resident may be declining, facility speaks with family and doctor, physician and hospice meet, then the RP and hospice meet to create a plan, then the facility and Responsible Party discuss it to ensure the plan can and will be implemented. Based on records review and interviews, LPA did not observe a preponderance of evidence standard that facility did not obtain a hospice care plan. Regarding allegation, "Staff did not maintain a comfortable temperature for resident" LPA observed a work order for 6/5/24 which R1 Responsible Party stated the air conditioner was not working. A work order was created, however, when maintenance checked the unit the cold air button was not pushed as the unit was in working condition. LPA and Administrator conducted a unit test during this visit and the unit in the same room was operating correctly. An interview conducted with Staff #3 (S3) during todays visit revealed that the room units are replaced when broken, and service is conducted for common area units. Based on observation, records review and interviews, LPA did not observe a preponderance of evidence standard that facility did not maintain a temperature in the facility that is in accordance with the regulations. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited. “This agency has investigated the complaint alleging the above mentioned allegations. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.” Exit interview held, and a copy of todays’ report provided.the state’s words, verbatim · CDSS document, Jan 15, 2025 · control 27-AS-20240910153451

Type of visit: Post Licensing

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - 1 Year visit on 9/17/24 at 12:00pm. LPA met with Kasie Wimmer and stated the purpose of todays visit. Administrator certificate expires 5/21/25. License fees are current. The facility is licensed for a capacity of 99 Non-ambulatory residents of which 15 may receive hospice care services. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. There is 9 resident receiving hospice care services. The most recent emergency drill was conducted on 8/29/24. LPA observed 2-day perishables and 7-day non-perishables. Facility has required postings which include Oxygen in Use. The temperature thermostats inside was observed to be at 75*F throughout the facility which is within the required range of 68-85*F. The hot water temperature was measured 114.2*F which is within the required range of 105-120*F. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, central heating and air and exit alarms in the facility. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited during this visit. Exit interview held. A copy of todays’ report provided.the state’s words, verbatim · CDSS document, Sep 17, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - 1 Year visit on 9/17/24 at 12:00pm. LPA met with Kasie Wimmer and stated the purpose of todays visit. Administrator certificate expires 5/21/25. License fees are current. The facility is licensed for a capacity of 99 Non-ambulatory residents of which 15 may receive hospice care services. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. There is 9 resident receiving hospice care services. The most recent emergency drill was conducted on 8/29/24. LPA observed 2-day perishables and 7-day non-perishables. Facility has required postings which include Oxygen in Use. The temperature thermostats inside was observed to be at 75*F throughout the facility which is within the required range of 68-85*F. The hot water temperature was measured 114.2*F which is within the required range of 105-120*F. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, central heating and air and exit alarms in the facility. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA reviewed 4 staff and 4 resident files during this visit. Upon a file review the following items were discussed to be submitted with any changes annually: Licensing fees-Current Criminal Record Clearances LIS536-Current Administrative Organization LIC309-Current Designation of Administrative Responsibility LIC308-Submit Personnel Report LIC500-Submit Affidavit Regarding Client/Resident Cash Resources LIC400-NA Surety Bond LIC402-NA Facility Floor Plan/Plot Plan LIC999-Current Fire Clearance (consistent with terms and limitations of license)-NA Qualifications of Administrator/Facility Manager-Submit Articles of Incorporation/Organization, Constitution and bylaws-NA Partnership Agreement-NA Control of Property-Submit Emergency Disaster Plan LIC610-Submit Plan of Operation (Restricted Health Care Plan)-NA Admission Policies and Procedures-NA Health Screening Report-Facility Personnel LIC503-NA Bacteriological Analysis of Private Water Supply-NA In-service Training Program-NA Medication Procedures-NA Transportation Procedures-NA Job Description/Personnel Policies-NA Exemptions/Waivers and Exceptions-Current First aid/CPR certificates-Current Liability Insurance-(if applicable)Submit Infection Control Plan-Submit if applicable Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited during this visit. Exit interview held. A copy of todays’ report provided.the state’s words, verbatim · CDSS document, Sep 17, 2024

Allegation investigated: Medication: Staff did not properly dispose of used needle.

On 6/12/24 at 9:00am Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced complaint inspection at Carlton Senior Living Sacramento Atrium RCFE to inform the licensee of complaint allegation mentioned above. Based on the interviews and statements obtained during the investigation process, the allegations are substantiated because LPA Gould interviewed two staff members who confirmed that an LVN staff member administered insulin to a resident and did not remove the needle in accordance with regulations. A PM staff member who attempted to administer medications at a later time was confirmed to be bricked by the exposed needle that was not disposed of according to regulations. The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of Medications is substantiated. Substantiated The following deficiency is cited per California Code of Regulations, TITLE 22. Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the home.the state’s words, verbatim · CDSS document, Jun 12, 2024 · control 27-AS-20240610125348

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(f)(2) · Plan of correction due date: Jun 14, 2024

Maintenance and Operation: Syringes and needles are disposed of in accordance with the California Code of Regulations, Title 8, Section 5193 concerning bloodborne pathogens. This requirement was not met as evidenced by statements from staff members confirming needle was not disposed of according to regulations resulting in a staff member finger prick which poses a potential health safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 12, 2024

Plan of correction: Facility has conducted in service training for staff members who assist residents with injections and training will be conducted quarterly to ensure staff meet regulations.

Type of visit: POC

On 6/12/24 at 11:00am LPA Kevin Gould Conducted a POC clearance. LPA confirmed POC documentation for in service training. POC letter generated.the state’s words, verbatim · CDSS document, Jun 12, 2024