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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701212
Report Date: 03/27/2026
Date Signed: 03/30/2026 09:08:28 AM

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
02/26/2026 and conducted by Evaluator Cynthia Tamayo
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20260226143817
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: 56DATE:
03/27/2026
UNANNOUNCEDTIME BEGAN:
09:06 AM
MET WITH:Christin PannellTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff do not respond to resident's requests for assistance in a timely manner.
Staff do not ensure that resident's hygiene needs are met.
Staff do not ensure incontinent needs are met.
INVESTIGATION FINDINGS:
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On 3/27/26, Licensing Program Analyst, LPA, Cynthia Tamayo arrived to the facility unannounced to complete and deliver complaint investigation findings into the above allegation. Upon arrival, LPA met with Senior Executive Assitant, Christin Pannell(S5), and Resident Liaison, Dionne Hamilton (S6), and Care Manager, Kayla Fermil (S7) explained the purpose of the visit. S5 called Director of resident services, Cal Mendiola (S3) via phone and LPA spoke with them via speaker phone as well.

Allegation 1: Staff do not respond to resident's requests for assistance in a timely manner.
It was alleged “Staff do not respond to resident's requests for assistance in a timely manner”, this investigation focused on Resident 1 (R1). Throughout the process, the LPA conducted facility observationsinterviewed staff and residents, collateral interviews, and reviewed all relevant documents related to R1. S5 stated R1 moved out by their family as of 3/22/26, due to the overall dissatisfaction

S2 stated there was an incident in which around 3:20 PM on 2/22/26, Resident 1’s (R1’s) family came for visit R1 and they reported the room was not cleaned and R1 was wet and needed to be changed.
[CONTINUED ON 9099-C1]
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2026
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 7
Control Number 27-AS-20260226143817
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: 03/27/2026
NARRATIVE
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S2 stated that R1's room was cleaned right away by staff once the family addressed the concern and an internal investigation was conducted. The investigation found that Care partner, Staff 4 (S4), in the morning did not meet expectations of cleaning R1 and R1's room. S2 stated they were in a rush and neglected to complete cleaning for R1. As a result, R4 received corrective action and where removed from the schedule pending additional training. On 3/4/26, LPA observed R1 pressed their call button and a care partner arrived to their room within one minute. S2 stated that the ideal response time is 5 minutes but it is “ideally” expected to be no more than 3-10 minutes.

Additionally, it was reported that on 3/4/26 at around 3:00 AM, R1 had back pain and they pressed their call button to request a Tylenol (PRN) medication for pain. Staff responded to the call and repositioned them in bed but did not return to give R1 the requested pain medication. S2 stated the missed medication was due to a staff feeling unwell and they went off shift without passing along the information to ensure R1 received the requested PRN medication.

Record review and Staff interviews confirm R1 was paying extra for medication management as the services are provided are a la cart. It was reported the facility is not requesting medication in time which may results in R1 missing medication doses on several occasions including 3/5/26 . On 3/9/26, the facility informing contacted R1's family to inform that R1 ran out of cholesterol/blood pressure medications. Record review of R1’s care plan indicated they receive Medication management is “Level 3 (11-20 medications)” and they receive medication management services. Medication and Reporting Requirement guidance was provided to S1 and S2. S2 stated medication was missed due to prescription being expired and they missed due to pharmacy delays March 2026.

It was reported that R1 was paying for the extra service to “be walked” and taken to activities but the service was removed since staff not taking R1 on walks or to activities timely or at all. Staff stated "escort services" were provided and there was not a known discrepancy with this service.

Additionally, S2 reported on December 8th 2025, there was a complaint reported to the facility by R1's family member (RP), in which R1 reported that care partners were not answering their calls. S2 and S6 corroborate that all of R1's calls were not being answered timely. On December 5th 2025, RP stated she called the community at approximately 1:45pm to request that the resident was dressed and ready for an outing by 4pm. S2 stated the family reported R1's brief was soiled upon arrival and they were not ready by the time requested . Dress Assist services were not met. S6 stated long wait times did occur of up to an hour or no response at all due to previous management and short staffing.
Based on interviews and record review, “Staff do not respond to resident's requests for assistance in a timely manner”, is substantiated.
CONTINUED ON 9099-C3
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 27-AS-20260226143817
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: 03/27/2026
NARRATIVE
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Allegation 2: Staff do not ensure that resident's hygiene needs are met.
It was alleged “Staff do not ensure that resident's hygiene needs are met”, this investigation focused on Resident 1. Throughout the process, the LPA conducted facility observations, interviewed staff and residents, collateral interviews, and reviewed all relevant documents related to R1.S2 and S5 reported R1 was moved out of the facility as of 3/22/26 due to overall dissatisfaction.

Staff corroborated reports that incontinent and hygiene needs were not met for R1. On 3/4/26, S2 stated that at around 3:20 PM on 2/22/26 Resident 1’s (R1’s) family came for visit R1 and they reported the room was dirty and R1 was wet and needed to be changed. The apartments was cleaned right away by staff and an internal investigation was conducted and it was found that Care partner, Staff 4 (S4), did not meet expectations of cleaning R1 and cleaning R1's room. S2 stated S4 reported they were in a rush and neglected to complete cleaning for R1. As a result, R4 received corrective action and where removed from the schedule pending additional training.

Additionally, on 2/24/26, a corrective action write up was given to Care Manger , Tonya Nepali (S3), whom was supposed to train all care staff, including S4. S2 stated S3 was terminated. S2 stated, that on 2/26/26, he apartment was not ”up to standard” as it was not cleaned; the room trash bin was not emptied out, and R1's Purewik device was not cleaned out. R1 uses an external catheter at night time and the facility is supposed to clean it every morning.

Staff, R1, and collateral persons interviewed stated showers and bathing are done once per week as stated on their service plan. On 3/4/26, LPA observed R1 and R1’s room was clean and free of odors. LPA was unable to confirm if R1’s wheelchair seat smelled of urine.

S6 stated long wait times did occur of up to an hour or no response at all due to previous management (S3) and short staffing.

Based on interviews and record review of the allegation “Staff do not ensure that resident's hygiene needs are met”, is substantiated.

[CONTINUED ON 9099-C4]
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Citations on this Visit Report are Under Appeal!

Control Number 27-AS-20260226143817
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: 03/27/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type B
03/30/2026
Section Cited
CCR
87625(b)(3)
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87625 Managed Incontinence(b) In addition to Section 87611, General Requirements for Allowable Health Conditions .. (3)Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met as evidenced by record review, interviews with staff, resident, and collateral interview, in which it was corroborated
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Staff stated that as of 3/11/26, the facility has begun to implement shift change cross over meetings for all shift changes, as well as to ensure charting system, Yardi, is being used daily by staff. S7 In service training on incontinent care will be held for staff. POC verification will be
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 Staff do not ensure incontinent needs for Resident 1 (R1) were being met at all times. This poses an immediate or potential health concern for residents' in care.
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faxed or emailed to the Regional Office by POC due date
Under Appeal
Type B
03/30/2026
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities ... shall have all ... personal rights ... (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not
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Since 3/11/26, the facility has begun to implement shift change cross over meetings for all shift changes, as well as to ensure charting system, Yardi, is being used daily by staff. S7 stated training regarding personal rights was conducted on 3/25/26.
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met, as evidence by interviews with staff, residents, and collateral interviews corroborating staff did not respond to resident 1 (R1's) requests for assistance in a timely manner. This poses an immediate or potential health concern for residents' in care
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POC verification will be faxed or emailed to the Regional Office by POC due date
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: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Citations on this Visit Report are Under Appeal!

Control Number 27-AS-20260226143817
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: 03/27/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type B
03/30/2026
Section Cited
CCR
87464(d)
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87464 Basic Services (d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified ...
This requirement was not met as evidenced by
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Staff reported that as of 3/11/26, the facility has begun to implement shift change cross over meetings for all shift changes, as well as to ensure charting system, Yardi, is being used daily by staff. S7 stated in service training will be held for staff. The POC verification will be faxed or emailed to the Regional Office by POC due date.
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record review and interviews with staff, resident, and collateral interview, in which it was corroborated that staff did not ensure that resident's hygiene needs were met for Resident 1 (R1). This poses an immediate or potential health concern for 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.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 27-AS-20260226143817
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: 03/27/2026
NARRATIVE
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Allegation 3: Staff do not ensure incontinent needs are met.
It was alleged “Staff do not ensure incontinent needs are met”, this investigation focused on Resident 1 (R1). Throughout the process, the LPA conducted facility observations, interviewed staff, residents, collateral interviews, and reviewed relevant documents related to R1. S2 and S5 reported R1 was moved out by their family as of 3/22/26 due to overall dissatisfaction.

Record review shows R1’s primary diagnosis is Dementia. R1’s “Assisted living assessment” was completed on 06/12/2025 for R1. R1’s Service Plan lists “Continence Care” in which “Resident will be offered assistance with toileting … Continence Care - 60 min/day … Staff will offer approximately 60 minutes of assistance per day while the resident uses the bathroom”. It is indicated that this is the responsibility of the Care Partner. Also, the plan details that the Care Partner “staff to be aware of resident's unique toileting needs. Indicate in notes … Purewick use during overnight”. Medication management is “Level 3 (11-20 medications)”. The “Residence and Service Agreement” state the following: “The appraisals described above and, in this Agreement, including those conducted at the time of admission and thereafter during your residency at The Community, are considered by us in determining, setting and monitoring staffing levels at The Community. We consider the appraisal and other factors to determine, set, or monitor staffing levels at The Community”.

The plan recommended the following additional services for R1: Continence Care -Monthly $ 995.00 / Monthly, Dress Assist 2 -Monthly $ 1000.00 / Monthly, Emergency Pendant -Monthly $ 55.00 / Monthly, Escort Assist -Monthly $ 700.00 / Monthly, Get Ready Assist -Monthly $ 340.00 / Monthly, Med Mgmt 2 - External Pharmacy -Monthly $ 1100.00 / Monthly, Shower Assist 1 -Monthly $ 250.00 / Monthly.

S2 stated that at around 3:20 PM on 2/22/26 Resident 1’s (R1’s) family came for visit R1 and they reported the room was not cleaned and R1 was wet and needed to be changed. The apartments was cleaned right away by staff and an internal investigation was conducted and it was found that Care partner, Staff 4 (S4), in the morning did not meet expectations of cleaning R1 and R1's room. S2 stated they were in a rush and neglected to complete cleaning for R1. As a result, R4 received corrective action and where removed from the schedule pending additional training.

Additionally, on 2/24/26, a corrective action write up was given to Care Manger , Tonya Nepali (S3), whom was supposed to train all care staff, including S4, S3 was terminated. S2 stated, the apartment was not ”up to standard” as it was not cleaned; the room trash was not cleaned , and R1's Purewik device was not cleaned out. R1 uses an external catheter at night time and the facility is supposed to clean daily.
[CONTINUED ON 9099-5]
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 27-AS-20260226143817
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: 03/27/2026
NARRATIVE
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Although a plan of correction was put in place prior in March 2026, it was reported that on 3/8/26 R1’s purewik external catheter was observed to not emptied out and cleaned until after 2:00PM on that day.
S6 stated long wait times did occur of up to an hour or no response at all. It is possible that R1 was left sitting for hours in soaked and soiled briefs.

It was alleged that a care staff advice whom no longer works at the facility would advise “doubling up” in which two diapers were used for R1, this would result in R1 getting irritations and pressure injuries. Staff are unaware of any staff advising to "double up". S1, S5, and S6 stated R1 preferred double padding and it was accommodated as it was the residents' preference but there was no "double briefing" as it is not allowed.

Based on interviews and record reviews the allegation "Staff do not ensure incontinent needs are met" is substantiated.

S5 stated that an interval investigation determined that Former Care Manger (S3) did not ensure to sufficient oversight over care staff. S7 (S7) was hired as of March 2026 as the new Care Manager in charge of oversight of care staff. Since starting, S7 is ensuring care staff calls button requesters are processed are responded to more thoroughly and that the facility is fully staffed and trained. In service training thus far include "Speak 2 Pendant Response" held on 3/21/26 and 3/25/26.

Previously staff was able to clear calls before being with the residents, however the updated training requires staff is physically with the resident before a call can be cleared and ensuing accuracy of meeting resident needs by implementation of online charting system, Yardi. Yardi, allows staff to chart after each service is completed by staff such as continence care, showers, meal assistance, escort service, etc. The charting system was in place before but was not being used by the former Care Manger, S3. S2 stated S7 was fired due to not enuring sufficient oversight over care staff. As 3/11/26, facility has implemented shift cross over meetings for all shift changes,

As a result, the allegations above are SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. Guidance on reporting requirements were provided. An exit interview was conducted with S7 and S5 and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2026
LIC9099 (FAS) - (06/04)
Page: 7 of 7