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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000295
Report Date: 12/16/2025
Date Signed: 12/16/2025 02:11:14 PM

Document Has Been Signed on 12/16/2025 02:11 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:KARLTON RESIDENTIAL CARE CENTERFACILITY NUMBER:
306000295
ADMINISTRATOR/
DIRECTOR:		ELENA WEINERFACILITY TYPE:
740
ADDRESS:3615 WEST BALL RD.TELEPHONE:
(714) 236-1170
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 76CENSUS: 49DATE:
12/16/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:33 PM
MET WITH:Weiner ElenaTIME VISIT/
INSPECTION COMPLETED:
01:32 PM
NARRATIVE
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Licensing Program Analyst (LPA) Samer Haddadin conducted an announced case management visit to the facility. LPA Haddadin was greeted and granted entry by Administrator (AD) Weiner Elena. The purpose of the visit was to address deficiencies identified during the investigation of complaint #22-AS-20250417112836. The following deficiencies were observed:

Per hospice records, between October 2023 and April 2025, R1 sustained at least nine documented falls. The earliest occurred on October 29, 2023, when R1 fell while attempting to transfer from bed to wheelchair. On November 2, 2023, Hospice record also showed that R1 had a skin tear to the left elbow. Facility had no records documenting regarding the falls or the skin tear. R1 sustained a second fall on November 8, 2023, and complained of left hip pain. R1 was transferred to Kaiser Hospital and diagnosed with left intertrochanteric femur fracture and underwent surgical repair the following day. R1 was later transferred to Post Acute Care for Rehabilitation. The facility’s internal self-report reflects the fall entry was not documented until November 29, 2023. Despite the seriousness of the incident, no significant changes were made to R1’s supervision schedule or care plan. On December 17, 2024, R1 complained of knee pain and swelling which was reported by the facility Med Tech to Vitas Hospice nurse. The visiting nurse prescribed Tylenol for R1’s pain and instructions to staff to monitor the swelling and contract hospice if needed. {***CONTINUE***809C}

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Samer Haddadin
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: KARLTON RESIDENTIAL CARE CENTER
FACILITY NUMBER: 306000295
VISIT DATE: 12/16/2025
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On December 26, 2024, R1 was observed to still have left knee swelling by the hospice doctor, however, facility staff denied R1 sustaining any fall. A subsequent X-ray completed on December 27, 2024, by Pacific Coast Mobile Radiology confirmed a complete transverse fracture of the distal left femur, resulting in a ten day delay of diagnosis and treatment of R1’s injuries.

On February 19, 2024, hospice documented that R1 was a high fall risk and uncooperative with transfers. On June 27, 2024, Hospice again documented that R1 was a high fall risk. Despite this, updates to the facility’s Needs and Services Plans dated May 18, 2023, May 18, 2024, and March 10, 2025, did not address R1’s increased needs of supervision. The facility did not revise the plans as required to reflect R1’s high fall risk and need for closer supervision and assistance.

Furthermore, between October 2023 and April 2025, the facility reported only one fall incident to Community Care Licensing, which was received on April 25, 2025. A search of the SIR portal system confirmed that no other fall incidents were reported during this period.

Based on record review, the following are being cited per Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report, confidential names list and appeal rights were provided at the time of exit.

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Samer Haddadin
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/16/2025 02:11 PM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Samer Haddadin On 12/16/2025 at 12:10 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: KARLTON RESIDENTIAL CARE CENTER
FACILITY NUMBER: 306000295

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
12/16/2025
Section Cited
CCR
87463(b)(1)(E

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87463(b)(1)(E) ".Appraisal, shall be updated in writing as frequently as necessary" Based on record review, the facility did not update R1’s Needs and Services Plan following significant changes
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Administrator will conduct training and update all current residents’ Needs and Services Plan and sent proof to LPA by POC due date
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 in condition, including nine falls resulting in two fractures between November 2023 and December 2024. The Needs and Services Plans dated May 18, 2023, May 18, 2024, and March 10, 2025, did not include individualized supervision requirements or interventions necessary to address R1’s fall risk needs. This posed an immediate health and safety risk to residents in care.
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Under Appeal
Type A
12/16/2025
Section Cited
CCR87465(a)(1)

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87465(a)(1)"licensee shall arrange, or assist in arranging, for medical care appropriate to the conditions and needs of residents"Based on record review, the facility did not ensure that R1 received timely medical attention following a change in condition.
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Licensee along with Administrator will conduct training to all staff and in the facility and signed and date training conducted; training must be filed, and send proof to LPA by POC due date
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On December 17, 2024, R1 sustained a fracture of the distal left femur; however, R1 did not receive an x-ray diagnosing the fracture until approximately 10 days after initial swelling. This posed an immediate health and safety risk to residents in care
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Samer Haddadin
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/16/2025 02:11 PM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Samer Haddadin On 12/16/2025 at 12:36 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: KARLTON RESIDENTIAL CARE CENTER
FACILITY NUMBER: 306000295

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type B
12/16/2025
Section Cited
CCR
87211(a)(1)(D)

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87211(a)(1)(D)"licensee shall furnish to the licensing agency such reports as the Department may require, including Any incident which threatens the welfare, safety or health of any resident" Based on record search of CCL SIR portal system the
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Licensee along with Administrator will conduct training to all staff as to when and how to report incidents to CCL, and send proof to LPA by POC due date
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facility did not report incidents involving R1 that threatened the resident’s health and safety: nine repeated fall resulting in at least two fractures between November 2023 and December 2024. The facility’s failure to submit the required incident reports posed a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Samer Haddadin
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2025


LIC809 (FAS) - (06/04)
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