CARLTON PLAZA OF ELK GROVE

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

" A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified ... Any incident which threatens the welfare, safety or health of any resident... " This requirement was not met as evidenced by: Based on interview and record review, an incident report was not sent to CCLD regarding a medication error, which poses a potential health, safety, and/or personal rights risk.

Official plan of correction

Licensee agrees to notify LPA Moleski of a planned training date regarding medication order transcriptions by POC due date. vincent.moleski@dss.ca.gov

Deadline recorded: Oct 17, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

" (4) The licensee shall assist residents with self-administered medications as needed. " This requirement was not met as evidenced by: Based on interviews and record review, a resident (R1) did not receive their regularly prescribed medication for more than six days, which poses an immediate health, safety, and/or personal rights risk.

Official plan of correction

Licensee agrees to notify LPA Moleski of a planned training date regarding medication order transcriptions by POC due date. vincent.moleski@dss.ca.gov

Deadline recorded: Oct 10, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

" (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. " This requirement was not met as evidenced by: Based on record review and interview, a resident's medication was mismanaged, which poses an immediate health, safety, and/or personal rights risk.

Official plan of correction

Licensee has already conducted a training regarding this product, dated July 24, 2025. This POC will be cleared.

Deadline recorded: Aug 13, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(d)

Regulation authority

CCR

What the official deficiency says

" (d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: " This requirement was not met as evidenced by: Based on record review and interview, staff nurses were not trained in the use of a medication-releasing intravaginal ring which they had been inserting for a resident, which poses a potential health, safety, and/or personal rights risk.

Official plan of correction

Licensee agrees to provide a written plan regarding how and when training is conducted for LVNs regarding medical devices or interventions. vincent.moleski@dss.ca.gov

Deadline recorded: Aug 22, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.312(d)

Regulation authority

HSC

What the official deficiency says

" Every facility required to be licensed under this chapter shall provide at least the following basic services: ... Being aware of the resident's general whereabouts, although the resident may travel independently in the community. " This requirement was not met as evidenced by: Based on interviews, record review, and observation, a resident's location was unknown for a period of approximately four hours while they were unsupervised in the community, which poses/posed an immediate health, safety, and/or personal rights risk.

Official plan of correction

Licensee agrees to send LPA Moleski a written plan regarding forthcoming training for any front desk personnel. vincent.moleski@dss.ca.gov

Deadline recorded: Jul 24, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87466

Regulation authority

CCR

What the official deficiency says

“The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.” This requirement was not met as evidenced by: Based on interviews and record review, appropriate assistance was not provided to R1 during their quarantine period, which poses an immediate health, safety, and/or personal rights risk.

Official plan of correction

Licensee agrees to provide LPA Moleski with a written plan regarding monitoring and observation of residents on quarantine by POC due date. Licensee agrees to include details in this written plan regarding the scheduling of a future staff training regarding observation of residents. Licensee further agrees to send LPA Moleski a sign-off sheet after this training is held. vincent.moleski@dss.ca.gov

Deadline recorded: Dec 31, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

“Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: … A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified … Any incident which threatens the welfare, safety or health of any resident…” This requirement was not met as evidenced by: Based on record review, an incident report was not sent to LPA Moleski regarding R1’s hospitalization on 8/8/24, which poses a potential health, safety, and/or personal rights risk.

Official plan of correction

Licensee agrees to conduct a staff training with managerial staff regarding reporting requirements and procedures by POC due date. Licensee further agrees to submit to LPA Moleski a sign-off sheet after this training is completed. vincent.moleski@dss.ca.gov

Deadline recorded: Jan 3, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

“(a) The facility shall be clean, safe, sanitary and in good repair at all times…” This requirement was not met as evidenced by: Based on interviews and record review, a resident’s room was not safe or sanitary, which poses an immediate health and safety risk.

Official plan of correction

Licensee agrees to schedule out a staff training regarding pet care requirements. Licensee agrees to provide LPA Moleski with a date or dates for this scheduled training by POC due date, and further agrees to provide LPA Moleski with a copy of a staff sign-in sheet after the training. vincent.moleski@dss.ca.gov

Deadline recorded: Dec 31, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(3)

Regulation authority

CCR

What the official deficiency says

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, S6 needs to be re-fingerprinted, and has been working without being associated to this facility, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/01/2024 Plan of Correction Licensee agrees to submit to LPA Moleski a written plan of correction, including a date when S6 has been scheduled to be re-fingerprinted. vincent.moleski@dss.ca.gov

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, R1 and R2 did not have annually updated LIC 602s on file, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/28/2024 Plan of Correction Licensee agrees to acquire updated LIC 602s for these residents by POC due date. vincent.moleski@dss.ca.gov

Official classification

Type B

Official code

1569.153

Regulation authority

HSC

What the official deficiency says

" A theft and loss program shall be implemented by the residential care facilities for the elderly within 90 days after January 1, 1989. The program shall include all of the following [subsections (a) through (m)]. " This requirement was not met as evidenced by: Based on observation, interviews, and record reviews, all required elements of the theft and loss program per 1569.153(a)-(m) were not implemented, which poses a potential health, safety, and personal rights risk.

Official plan of correction

Licensee agrees to update theft and loss policies and procedures and to provide LPA Moleski updated documentation when completed. vincent.moleski@dss.ca.gov

Deadline recorded: Jun 6, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

Personnel Requirements: " Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. " This requirement was not met as evidenced by: Based on record review and interviews, there are not a sufficient number of staff at this facility to answer resident calls in a timely manner, which poses a potential health and safety risk.

Official plan of correction

Licensee agrees to conduct a staff training regarding call response procedures. Licensee agrees to submit a plan to address staffing needs. Licensee agrees to email LPA Moleski a copy of the staff training sign-in sheet and the above mentioned written plan. vincent.moleski@dss.ca.gov

Deadline recorded: Oct 20, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

" (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. " This requirement is not met as evidenced by: Deficient Practice Statement Based on review of S3, S4 and S7's personnel records, the licensee did not ensure S3, S4, or S7 maintained active first aid certifications, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/10/2023 Plan of Correction Licensee agrees to schedule and/or conduct a staff training to include at a minimum S3, S4 and S7 regarding first aid/CPR by the POC due date. Licensee agrees to send records of scheduling and/or conducting this training to LPA Moleski. vincent.moleski@dss.ca.gov

Official classification

Type A

Official code

87470(b)(2)(B)

Regulation authority

CCR

What the official deficiency says

“PPE shall be removed and discarded in the nearest appropriate waste receptacle with a tight-fitting cover immediately upon completing a task.” This was not met based on LPA interviews with staff members.

Official plan of correction

Administrator will conduct staff training on proper disposal of PPE.

Deadline recorded: Apr 20, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87211(a)(2)

Regulation authority

CCR

What the official deficiency says

87211(a)(2) Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports...(2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents...This was not met as evidenced by: Based on the incident report dated 1/19/2023 received from the licensee there was a Covid 19 outbreak that began on 1/15/2023. According to Title 22 Regulations, the outbreak was not reported within regulatory timelines. This poses an immediate health and safety risk to persons in care.

Official plan of correction

Licensee stated there will be a training conducted on reporting requirements for outbreaks and infections and will submit a copy of the sign in sheet for the training to LPA no later than 2/4/2023 5pm.

Deadline recorded: Feb 3, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(d)(3)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care. (d) If the resident is unable to determine his/her own need for a...nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff..., shall be permitted to assist the resident with self-administration provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record. This requirement is not met as evidenced by: Based on interview and record review, a Quetiapine as needed medication for R1 is missing 22 pills from original container filled on 7/17/21 with no record from staff to indicate when medication was given, dosage taken, and R1s response to medication. This poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee to conduct medication training for all appropriate staff. Training to include but not be limited to: medication documentation, physician’s orders, assisting residents with self-administration of medication. Training date to be submitted to LPA by POC due date. Proof of completed training to be submitted to LPA within 2 days of full completion. Full completion date shall not exceed 14 days from today’s date of 5-16-22. Licensee to conduct a full medication audit for memory care residents including but not limited to medication orders with matching medication log sheets and central storage records, medication counts, and accompanying medication documentations. Date of audit start to be submitted to LPA by POC due date and completed audit results to be submitted to LPA within 2 days of full completion. Full completion date shall not exceed 14 days from today’s date of 5-16-22.

Deadline recorded: May 17, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87628(b)(4)

Regulation authority

CCR

What the official deficiency says

87628(b)(4) Diabetes. (b)In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (4) Providing modified diets as prescribed by a resident's physician as specified in Section 87555(b)(7). This requirement is not met as evidenced by: Based on interview, R1 was provided a maple syrup product by staff which was not low or sugar free and inconsistent with R1’s modified diet physician's order. This poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee will read regulation 87628 and submit a signed declaration of understanding to LPA by POC due date. Licensee will submit a plan which ensures residents with modified diets are receiving such diets as appropriate. Plan to be submitted to LPA by POC due date.

Deadline recorded: May 26, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(b)(2)

Regulation authority

CCR

What the official deficiency says

Care of Persons with Dementia In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including: Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. This requirement is not met as evidenced by: the resident awol'd twice from the facility Based on the facility did not implement any new measures to prevent future awols from re-occurring. This possess an immediate health and safety risk to residents in care.

Official plan of correction

Licensee shall submit a plan by POC Due date on how this will be addressed with the staff to ensure the safety of the residents.

Deadline recorded: Apr 29, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(j)

Regulation authority

CCR

What the official deficiency says

Care of Persons with Dementia The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement is not met as evidenced by: the resident awol'd twice from the facility and the front door alarm did not sound Based on interviews the resident eloped out the front door. This possess an immediate health and safety risk to residents in care.

Official plan of correction

Licensee shall submit a plan by POC Due date on how this will be addressed with the staff to ensure the safety of the residents.

Deadline recorded: Apr 29, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(k)(6)

Regulation authority

CCR

What the official deficiency says

Care of Persons with Dementia The following initial and continuing requirements must be met…without violating Section 87468, Personal Rights, facility staff shall ensure the continued safety of residents if they wander away from the facility. This requirement is not met as evidenced by: R1 wandered from the facility at least twice. Based on interviews and documentation, the Licensee did not ensure supervision resulting in R1 wandering away from the facility twice with the most recent being approximately 8 hours. This possess an immediate health and safety risk to residents in care.

Official plan of correction

Administrator shall submit a plan on how the facility will secure supervision of the residents which shall be faxed by POC due date.

Deadline recorded: Apr 29, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

00000

Regulation authority

CCR

What the official deficiency says

NA NA

Official plan of correction

NA

Deadline recorded: Apr 29, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87211(a)(D)

Regulation authority

CCR

What the official deficiency says

Reporting Requirements Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:Any incident which threatens the welfare, safety or health of any resident...unexplained absence of any resident. This requirement is not met as evidenced by: A review of submitted SIRs of which one was not found for the previous date R1 AWOL'd on 4/22/22. Based on interviews the Administrator did not submit a report for the AWOL incident that occurred on 4/22/22. This possess an immediate health and safety risk to residents in care.

Official plan of correction

Licensee shall submit via fax by POC due date a statement that Title 22 Regulations will be followed at all times.

Deadline recorded: Apr 29, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(j)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care In all facilities licensed for sixteen (16) persons or more...designated as having primary responsibility for assuring that each resident receives needed first aid... This requirement is not met as evidenced by:R1 did not receive first aid due to eating Based on interviews the Administrator confirmed that R1 did not receive first aid because after eating the family took R1 on an outting. This possess an immediate health and safety risk to residents in care.

Official plan of correction

Licensee shall submit a plan via fax by POC due date that an in-service will be conducted regarding staff duties to be performed.

Deadline recorded: Apr 29, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(5)

Regulation authority

CCR

What the official deficiency says

A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following. The licensee shall assist residents with self administered medications as needed. This regulation was not met as evidenced by based on LPA’s interviews and a review of the facility records, this facility did not ensure that the correct medication was administered to R1 on 5-27-21 and 9-26-21. R1 received the wrong medication and dosage on each date.

Official plan of correction

The facility will provide medication training for both medical technicians from 5-27-21 and 9-26-21 dates. Both Medical technicians have attended the medication trainging on 10-19-2021.

Deadline recorded: Oct 28, 2021. A deadline is not proof that correction was completed.