Carlton Senior Living Sacramento

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: Uncleared individuals are providing care and supervision.

Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced on April 28, 2026, at 7:00 AM to open and deliver complaint findings, LPA Martinez met with Christin Pannell and explained the purpose of the visit. Throughout the course of the investigation, LPA Martinez conducted interviews and reviewed facility files. It was learned that staff 1 (S1) was allowed to work at this facility prior to obtaining criminal record clearance documentation and approval from Community Care Licensing Department (CCLD). S1 worked at this facility from December 12, 2025 to April 17, 2026. Violation of Section 87355(e) shall result in an immediate assessment of civil penalties. A civil penalty in the amount $500.00 shall be assessed on April 28, 2026. An exit interview was conducted, and a copy of this 9099 report, 9099-D Page, LIC421BG, and appeals rights documentation was provided to Christin Pannell. Substantiatedthe state’s words, verbatim · CDSS document, Apr 28, 2026 · control 27-AS-20260422152033

Allegation investigated: Staff does not treat resident with dignity and respect

On 3/4/26 Licensing Program Analyst (LPA) Cynthia Tamayo arrived unannounced to complete and close the investigation into an allegation noted above. LPA met with Administrator, Kasie Wimmer(S1) and Director of Memory Care Rose De La Garza (S2), LPA stated the purpose of this visit. Allegation: Staff does not treat resident with dignity and respect It was alleged “staff yelled at resident”, this investigation focused on Resident 1 (R1). Throughout the process, the LPA conducted interviewed staff, collateral interviews, and reviewed all relevant documents related to R1. On 2/3/26, the facility received a report from a witness stating that Resident 1 (R1) was not treated with respect by staff 3 (S3). On 2/10/26, the facility self reported to the Regional Office via an incident report and SOC 341 that on 2/3/26, R1 wondered into another resident’s’ room in which a witnessed reported that they overheard S3 calling R1 “stupid” in a “frustrated” tone. It observed through video footage to assithe state’s words, verbatim · CDSS document, Mar 4, 2026 · control 27-AS-20260205131706

Allegation investigated: Staff do not ensure that placemats used for meal services are kept in a sanitary condition.

Licensing Program Analyst, LPA, Noel Wolf Petersen arrived unannounced to the facility, to conduct an investigation into the above allegation. LPA met with Cal Mendiola to explain the purpose of the visit. LPA arrived during a dinner service and did observe a condition of general cleanliness with regards to the floors, cultery, plates, tables, and placemats. LPA also observed a roach trap in the kitchen managers office. LPA interviewed 5 clients, none reported a recent history of uncleanliness with regards to the kitchen, the dining area, or the staff. All found the staff to be responsive to sudden messes, and attentive to thier needs. LPA interviewed 4 staff, kitchen staff have a mix of statements regarding improvements in cleanliness, one in support of a potential risk to the development of bacterial colonies if the placemats are not allowed to air dry properly. Kitchen manager provided a statement that the placemats are chemically treated to prevent development of colonies and the rthe state’s words, verbatim · CDSS document, Jan 22, 2026 · control 27-AS-20250930151234

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: Licensee did not ensure facility was adequately treated for pests Staff did not ensure resident was provided with bathing services Staff did not ensure residents room was kept in clean sanitary conditions

On 07/07/2025, Licensing Program Analysts (LPA) Arielle Pascua and Triel Lindstrom arrived unannounced to this facility to conduct a complaint visit. LPA met with FDR Rose Dela Garza and explained the purpose of the visit. The purpose of this visit was to deliver complaint findings for the allegations above. Current census was 131. A brief interview with FDR was conducted. Allegation: Licensee did not ensure facility was adequately treated for pests. It was alleged that the licensee failed to ensure the facility was adequately treated for pests. During the course of the investigation, the department conducted interviews, made observations, and reviewed facility records. On March 27, 2025, Licensing Program Analysts (LPAs) Kimberly Viarella and Sommer Hayes conducted observations in three adjacent bedrooms. No evidence of pests was found in one of the rooms; however, further inspection of the remaining two bedrooms revealed several small, flat, black bugs along the baseboards and behindthe state’s words, verbatim · CDSS document, Jul 7, 2025 · control 27-AS-20250324141824

Allegation investigated: Staff are not meeting resident's care needs

Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility on 05/22/25 to continue this investigation into the above allegation. LPA identified herself upon arrival, stated the purpose of the visit, and asked to meet with the Designated Facility Administrator/Executive Director (ED). LPA met with Cal Mendiola and a brief interview followed. Based on a review of records combined with information gathered from interviews, R1 was not receiving their necessary incontinent care. An entry made on 08/18/24 stated that R1 was not changed prior to the PM shift coming on duty and R1 and their bed “was soaking wet.” On 8/28/24, it was also noted that R1 had a large bowel movement and that R1 was not changed prior to the PM shift coming on duty. Additional care notes entered in the ALIS computer system, also described the following on 08/11/24 by 3 care partners. At 6:02, S3 wrote, “Care partners were not able to do last rounds because resident was unable to standthe state’s words, verbatim · CDSS document, May 22, 2025 · control 27-AS-20241015143137

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: Personal Rights

On 1/23/25, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver the findings of this complaint investigation. The LPA identified herself upon arrival, stated the purpose of the visit, and asked to meet with the Designated Facility Administrator. LPA met with Kasie Wimmer and a brief interview followed. A resident (R1) sustained a fall on 5/28/24 in the common area of the facility while trying to transfer independently from a chair into their wheelchair. R1 was taken to Kaiser Permanente. R1 had a CT scan which showed no acute hemorrhage or calvarial fracture and no mass effect of herniation. Tylenol was given for pain. Discharge paperwork listed to monitor R1 and if symptoms got worse, to bring R1 back to the hospital. R1 returned to the facility. On 5/29/24, R1 entered a different resident's room and sustained a fall at approximately 1303 hours. R1 remained on the floor in a pool of blood until facility staff entered the room at apprthe state’s words, verbatim · CDSS document, Jan 23, 2025 · control 27-AS-20240624162127

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: 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 open the initial investigation of the above mentioned allegations on 9/10/24 at 3:15p. LPA met with Kasie Wimmer and stated the purpose of the visit. LPA obtained information that the resident does not reside at this facility. Based on interview with Exective Director/Administrator Kasie Wimmer the allegation(s) are deemed Unfounded."The allegation is UNFOUNDED, meaning that the allegation was false, could not have happened and/or was without a reasonable basis. This Department has therefore dismissed the complaint." Per California Code of Regulations, no deficiencies were observed or cited. Exit interview held, and a copy provided. Unfoundedthe state’s words, verbatim · CDSS document, Sep 10, 2024 · control 27-AS-20240905163918

Allegation investigated: Facility staff sexually abused resident in care

On 6-20-24 at 2:50pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver and discuss findings for the complaint allegation noted above. LPA met with Administrator Kasie Wimmer and explained the purpose of the visit. During this investigation, the Department conducted interviews with resident1 (R1) and additional witness. The department also reviewed facility file documentation including SOC 341 abuse report, resident and services agreement, physician's report for R1, Activities of Daily LIving (ADL) questionnaire for physician review, resident health identification information, key lock audits, observation notes dated 4-2-2024 to 5-6-2024, resident roster, staffing roster, staff schedules for April 2024 to May 2024, and assisted living/memory care staff contact information. Based on interviews and record reviews, it was determined that R1 was unable to identify a suspect male or female. Interviews conducted further revealed facility staff performed duties tothe state’s words, verbatim · CDSS document, Jun 20, 2024 · control 27-AS-20240506161153

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