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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701212
Report Date: 05/14/2025
Date Signed: 05/14/2025 05:15:15 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/07/2025 and conducted by Evaluator Kimberly Viarella
COMPLAINT CONTROL NUMBER: 27-AS-20250507202155
FACILITY NAME:CARLTON SENIOR LIVING SACRAMENTO ATRIUMFACILITY NUMBER:
342701212
ADMINISTRATOR:KASIE WIMMERFACILITY TYPE:
740
ADDRESS:1071 FULTON AVENUETELEPHONE:
(916) 971-4800
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:99CENSUS: 52DATE:
05/14/2025
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Cal MendiolaTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Medications are not being destroyed as required.
INVESTIGATION FINDINGS:
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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 Manager explained that these resident medications were supposed to be destroyed
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 27-AS-20250507202155
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: CARLTON SENIOR LIVING SACRAMENTO ATRIUM
FACILITY NUMBER: 342701212
VISIT DATE: 05/14/2025
NARRATIVE
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and stated that they had 7 days in which to do so. LPA was told these medications were for 2 residents. One medication was in the appropriate prescription bottle. Another medication was in a medication cup with the resident information hand written on the lid. There were 2 other medication cups without any resident information on them.

LPA asked for copies of the Electronic Medication Record (EMAR) for these two residents to see if any notes were included to describe why these medications were in the Medication Manager's possession. The Medication Manager stated that 1 medication crumbled when cut in half and could not be counted or administered. LPA was told that another medication was found on the floor of a resident's room, and the last pill was found in a resident's bedding. There were no notes in the EMAR accounting for these medications or that they were turned into the Medication Manager for destruction.

This LPA also learned during the course of this investigation that it was the practice of this facility not to log the destruction of pills found /not taken. Pills were only logged in the centrally stored destruction log if staff found more than one. LPA provided technical assistance regarding the recording and destruction of medications.

The standard for the preponderance of evidence was met and the Department found this allegation to be SUBSTANTIATED.

According to the California Code of Regulations, Title 22, this deficiency was cited on the LIC 9099D page.

A copy of this report was provided along with APPEAL RIGHTS.

Exit interview.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/07/2025 and conducted by Evaluator Kimberly Viarella
COMPLAINT CONTROL NUMBER: 27-AS-20250507202155

FACILITY NAME:CARLTON SENIOR LIVING SACRAMENTO ATRIUMFACILITY NUMBER:
342701212
ADMINISTRATOR:KASIE WIMMERFACILITY TYPE:
740
ADDRESS:1071 FULTON AVENUETELEPHONE:
(916) 971-4800
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:99CENSUS: DATE:
05/14/2025
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Cal MendiolaTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff do not ensure that medications are locked and inaccessible to residents.
INVESTIGATION FINDINGS:
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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 a walkthrough of the Wellness Center, offices, and also conducted staff interviews. The medications that the reporting party alleged were accessible to residents in care were in an area of the facility behind the reception desk where only staff were allowed. LPA had to travel through the Wellness Center to the Medication Manager's office, which was locked when this LPA checked the door herself. LPA was told by 4 out of 5 staff interviewed that this office was shared by the Community Liaison and only unlocked when either of these two staff members were in it.

The department found this allegation to be UNSUBSTANTIATED. A finding of unsubstantiated does not
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20250507202155
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: CARLTON SENIOR LIVING SACRAMENTO ATRIUM
FACILITY NUMBER: 342701212
VISIT DATE: 05/14/2025
NARRATIVE
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mean that the allegation is not true or did not happen, it means that there was not enough evidence to substantiate the allegation.

According to the California Code of Regulations, no deficiencies were cited during today's visit. A copy of this report along with APPEAL RIGHTS wer provided. Exit interview.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20250507202155
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CARLTON SENIOR LIVING SACRAMENTO ATRIUM
FACILITY NUMBER: 342701212
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/15/2025
Section Cited
CCR
87465(i)
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Incidental Medical and Dental Prescription medications which are not taken ..physician and documented in the resident’s record nor disposed of according shall be destroyed ...which lists the following:
The Licensee di not ensure the above regulation was enforeced as evidenced by:
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Executive Assisted/Designee stated that he will be submitting a detyailed plan for staff training which will include destruction proceducures, documentation, med passes, developing a new log/procedure for pills found. This will be submittied to CCL by the close of business 05/15/25 by emailing:
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The LPA observed 4 resident medications in the unlocked desk of the Medication Manager (MM). The MM could not provide documentation explaining why these meds were in their drawer waiting to be destroyed. This posed an immediate risk to the put the health safety and personal rights of residents in care.
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cclascpsacramentoro@dss.ca.gov
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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.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5