Carlton Senior Living Sacramento Atrium

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 therthe state’s words, verbatim · CDSS document, Mar 27, 2026 · control 27-AS-20260226143817

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 repothe 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

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

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 Mthe state’s words, verbatim · CDSS document, May 14, 2025 · control 27-AS-20250507202155

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. Uthe state’s words, verbatim · CDSS document, Jan 15, 2025 · control 27-AS-20240910153451

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

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. Substantiatedthe state’s words, verbatim · CDSS document, Jun 12, 2024 · control 27-AS-20240610125348

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.