Carlton Plaza Of Elk Grove

Allegation investigated: Staff are not administering medication(s) to resident in care as prescribed.

Licensing Program Analysts (LPAs) Vincent Moleski and Triel Lindstrom arrived unannounced to open this complaint. LPA Moleski met with facility administrator Jennell Revera and explained the purpose of the visit. This investigation consisted of record review and interviews. LPA Moleski interviewed Revera and two staff members (S1-S2). In an interview, the facility's medication manager (S1) admitted that there had been a medication error for a resident (R1). S1 said that R1 had not been receiving a medication used to treat Parkinson's disease for several days due to an error in transcribing the prescription order into the facility's medication administration records (MARs). S1 said that R1 missed four daily doses of the medication between September 18 and September 25. [continued on 9099-C] Substantiatedthe state’s words, verbatim · CDSS document, Oct 9, 2025 · control 27-AS-20251003122158

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.

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: Resident suffered injuries due to staff neglect

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with facility administrator Jennell Revera and explained the purpose of the visit. This investigation consisted of interviews, observation and record review. LPA Moleski interviewed Revera, 18 staff members (S1-S18), and one resident (R1). LPA Moleski reviewed an incident report log for R1 dating between 5/22/24 and 10/19/24. On 5/22, R1 was using their wheelchair as a walker, causing R1 to lose their balance and fall. R1 did not hit their head but had some bruising on their left hand and right leg and some redness on their back. On 7/28, R1 suffered a fall which was captured on camera. R1 tried to sit in their wheelchair, but missed and fell on their left side. R1 had no apparent injuries at the time. However, on 7/30, a staff member observed some bruising on R1's left hip. [continued on 9099-C] Unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 16, 2025 · control 27-AS-20240823101614

Allegation investigated: Staff did not ensure that resident's room was kept clean

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with facility administrator Jennell Revera and explained the purpose of the visit. This investigation consisted of interviews and record review. LPA Moleski conducted interviews with Revera, a resident (R1), three family members of R1 (R1’s RPs 1-3) and 11 staff members (S1-S11). LPA Moleski reviewed an internal facility incident report, dated 8/8/24, which described R1 experiencing increased confusion. R1’s responsible parties called for emergency medical services, and R1 was taken to the hospital for treatment, according to the internal incident report. The Community Care Licensing Division did not receive an incident report regarding this incident, as required per 22 CCR 87211(a)(1)(D). This deficiency will be addressed in a subsequent case management visit. [continued on 9099-C] Substantiatedthe state’s words, verbatim · CDSS document, Dec 30, 2024 · control 27-AS-20240813084041

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.

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 did not provide adequate food service Staff did not meet resident's toileting needs Staff did not meet resident's showering needs Staff did not treat resident with respect Staff overcharged resident Staff mismanaged resident's medication

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with facility administrator Jennell Revera and explained the purpose of the visit. This investigation consisted of interviews, observation and record review. LPA Moleski interviewed Revera, 10 staff members (S1-S10), four residents (R1-R4), and a resident’s responsible party (R1’s RP). In an interview, R1 said that R1 liked the food at the facility, and always gets enough to eat. R1 said they had not missed any meals at the facility. R1 said that they preferred to have meals delivered to their room, rather than going downstairs to eat. R1 said staff assisted them with showers, and said they received showers about once every other day. R1 said they received enough showers, and in fact would prefer fewer showers, as R1 is often tired in the mornings. [continued on 9099-C] Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 1, 2024 · control 27-AS-20240327145359

Allegation investigated: Facility staff did not safeguard residents belongings

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with director of resident services Andrea Quintanilla and explained the purpose of the visit. This investigation consisted of observation, interviews, and record review. LPA Moleski interviewed facility administrator Jennell Revera, two staff members (S1-S2), and a former resident’s responsible party (R1’s RP). LPA Moleski reviewed a death report for a resident (R1) dated 4/17/24. The death report states that R1’s RP notified the facility on 4/7/24 that two of R1’s rings were missing. Staff searched various areas for the missing rings, but were unable to locate the rings, according to the death report. Local law enforcement was notified and a report number was provided. LPA Moleski reviewed an incident report dated 4/25/24, stating that R1’s RP notified staff that three of R1’s rings were missing. [continued on 9099-C] Substantiatedthe state’s words, verbatim · CDSS document, May 9, 2024 · control 27-AS-20240501152638

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: Due to lack of staffing, staff do not answer resident call buttons timely

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with director of resident services Andrea Quintanilla and explained the purpose of the visit. This investigation consisted of record review and interviews with staff and residents. During an interview, Jennell Revera said staff are expected to respond to pendant calls within 15 minutes. Revera said staff hours were recently reduced. LPA Moleski reviewed 30 days of call button responses for a resident (R1), dated from July 30, 2023 to August 29, 2023. [continued on 9099-C] Substantiatedthe state’s words, verbatim · CDSS document, Oct 10, 2023 · control 27-AS-20230823160535

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