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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347005464
Report Date: 12/30/2024
Date Signed: 12/30/2024 09:56:11 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
08/13/2024 and conducted by Evaluator Vincent Moleski
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240813084041
FACILITY NAME:CARLTON PLAZA OF ELK GROVEFACILITY NUMBER:
347005464
ADMINISTRATOR:JENNELL REVERAFACILITY TYPE:
740
ADDRESS:6915 ELK GROVE BLVD.TELEPHONE:
(916) 714-2404
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:180CENSUS: 140DATE:
12/30/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jennell ReveraTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Staff did not ensure that resident's room was kept clean
INVESTIGATION FINDINGS:
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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]
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024
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 6
Control Number 27-AS-20240813084041
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 PLAZA OF ELK GROVE
FACILITY NUMBER: 347005464
VISIT DATE: 12/30/2024
NARRATIVE
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In interviews, two family members of R1 (R1’s RP 1-2) said they visited this facility on 8/8/24. R1’s RP 1 said that when they arrived at R1’s room, they observed cat feces on the floor, which R1 had stepped in and tracked all over the apartment. R1’s RP 1 described a “stench” in R1’s room from the feces. R1’s RP 2 said they also observed cat feces on the floor, as well as on R1. R1’s RP 1 said that after this incident, R1’s cats had to be rehomed.

LPA Moleski reviewed R1’s resident records. R1’s care plan at the time, dated 8/5/24, indicated that R1 was to receive assistance from facility staff with cleaning a litter box for cats three times per week. R1’s RP 2 said that there had been numerous previous instances wherein R1’s litter box was not cleaned. R1’s RP 1-2 both said that R1’s box appeared as if it had not been scooped for several days at the time of their visit on 8/8/24.

LPA Moleski reviewed progress notes for R1 and observed a note authored by a staff member (S6) dated 8/5/24. In the note, S6 described checking on R1, and upon entry to R1’s room, observing cat feces on the floor. The note reads in part: "… as I was in there I noticed cat poop everywhere. [R1] has dried cat poop on [R1’s] feet, it's on the carpet by [R1’s] bed, it's dried and smashed on [R1’s] bathroom floor and it's all under [R1’s] nails. We spent 10 minutes washing it off [R1’s] nails. I washed it off [R1’s] feet with a towel as well. Notified manager [R1] needs some additional help getting [R1’s] room cleaned up."

In an interview, S6 said that the events described in the note occurred on the day that R1 was sent to the hospital, 8/8/24. S6 reiterated the events as described in the above note, and added that S6 did not know how long the feces had been on the floor and on R1, but said that the feces was dry and difficult to remove from R1. S6 said that R1 was very confused at the time and did not even know the feces was there.

LPA Moleski reviewed R1’s care tracking sheets from the time of the incident as described above. LPA Moleski observed that staff members had signed off on 8/2/24, 8/5/24, 8/6/24, and 8/7/24 that they had provided assistance with cleaning R1’s litter box. LPA Moleski reviewed recorded care reports for R1’s pet care and observed that on 7/22/24, a staff member indicated they were “not able to get to” the pet care.

[continued on 9099-C]
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 27-AS-20240813084041
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 PLAZA OF ELK GROVE
FACILITY NUMBER: 347005464
VISIT DATE: 12/30/2024
NARRATIVE
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In an interview, S1, who had signed off on R1’s pet care tracking sheet on 8/2/24 and 8/7/24, said that they were aware that the litter box was not consistently cleaned. “It was not a task people were doing,” S1 said. S1 said that they would often observe the litter box “very full” with feces and “saturated” with urine. S1 said that staff were “constantly” reminded that the litter box was not being cleaned regularly.

In an interview, S2, who signed off on R1’s pet care tracking sheet on 8/5/24, said that the litter box “wasn’t being cleaned a lot.” S2 said that the litter box often presented a “foul odor.” S2 said there was frequently litter and cat hair all over R1’s room. S2 said they would often need to open a window in R1’s room due to the strong smell of urine. S2 said that although they did not observe the incident described by S6 wherein cat feces was on the floor in R1’s room, they were aware that R1’s carpets needed to be shampooed afterward.

In an interview, S3 said they would “barely set foot” in R1’s room due to the smell from the litter box. S3 was not sure if R1’s room was clean or not, because they usually did not want to enter. S3 said they would have R1 come to the door to give R1 their medications. In an interview, S4 said that R1’s room was “a bit of a mess” on 8/8/24. S4 said that, based on their observations, it did not appear that R1’s litter box was being cleaned. S5 said that they had previously observed cat feces on the floor in R1’s room, but was not sure if it was 8/8/24, or a different day. S5 said that R1’s room usually smelled from the litter box. S11 said that R1’s room had “strong odors” from R1’s litter box.

The department has determined the following as it relates to the allegation that staff did not ensure that a resident’s room was kept clean:

Based on interviews and record review, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met.

This facility is hereby cited per 22 CCR Section 87303(a). An exit interview was held with Revera. Appeal rights and a copy of this report were left with Revera.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 27-AS-20240813084041
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 PLAZA OF ELK GROVE
FACILITY NUMBER: 347005464
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/31/2024
Section Cited
CCR
87303(a)
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“(a) The facility shall be clean, safe, sanitary and in good repair at all times…” This requirement was not met as evidenced by:
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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
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Based on interviews and record review, a resident’s room was not safe or sanitary, which poses an immediate health and safety risk.
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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: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
08/13/2024 and conducted by Evaluator Vincent Moleski
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240813084041

FACILITY NAME:CARLTON PLAZA OF ELK GROVEFACILITY NUMBER:
347005464
ADMINISTRATOR:JENNELL REVERAFACILITY TYPE:
740
ADDRESS:6915 ELK GROVE BLVD.TELEPHONE:
(916) 714-2404
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:180CENSUS: 140DATE:
12/30/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jennell ReveraTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Due to negligence, resident became dehydrated and developed sepsis, which resulted in hospitalization.
Staff did not administer resident's medication as prescribed
INVESTIGATION FINDINGS:
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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 medical records related to R1’s hospitalization on 8/8/24. According to R1’s medical records, R1 was diagnosed with lactic acidosis, acute renal insufficiency, hyponatremia, and leukocytosis upon admission to the emergency room. R1 was given intravenous fluids and was prescribed an antibiotic while in the hospital. R1 was assessed to have "severe intravascular volume depletion causing lactic acidosis" and "acute renal insufficiency due to poor oral intake and med/viral syndrome induced diarrhea due to Paxlovid and COVID-19 viral infection." [continued on 9099-C]
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 27-AS-20240813084041
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 PLAZA OF ELK GROVE
FACILITY NUMBER: 347005464
VISIT DATE: 12/30/2024
NARRATIVE
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Later in this same assessment, R1’s lactic acid elevation was said to be "likely due to poor oral intake plus diarrhea due to Paxlovid and COVID-19 viral infection." Notes regarding R1’s diarrhea indicated that it is a "noted side effect of Paxlovid and also could be COVID related as well."

Nowhere in R1’s medical records from this hospitalization was R1 diagnosed with sepsis. For this reason, the allegation on this complaint regarding sepsis is determined to be unsubstantiated. However, additional deficiencies regarding R1’s care during this same time period will be addressed in a separate case management report. Additionally, The Community Care Licensing Division did not receive an incident report regarding R1’s hospitalization, as required per 22 CCR 87211(a)(1)(D). This deficiency will be addressed in the same case management report, which will be delivered today.

LPA Moleski reviewed R1’s medication administration records dating from R1’s COVID-19 quarantine period. R1 received all medications as prescribed, according to the MARs. None of the staff members interviewed (S1-S11) were aware of any issues with R1’s medication during their quarantine period. LPA Moleski interviewed the medication technician who was scheduled to provide R1 with their medications the day R1 was hospitalized, 8/8/24 (S3). S3 said that they did give R1 their medications on that date, and R1 took them all without incident. In an interview, R1 said they have never missed a dose of their medications, and has had no issues with their medication administration.

The department has determined the following as it relates to the allegations that, due to negligence, a resident became dehydrated and developed sepsis, which resulted in hospitalization, and that staff did not administer a resident’s medication as prescribed:

Based on interviews and record review, the above allegations are UNSUBSTANTIATED, which means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

No deficiencies were cited regarding the above allegations. An exit interview was held and a copy of this report was left with Revera.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6