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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347005464
Report Date: 01/16/2025
Date Signed: 01/16/2025 12:04:28 PM

Unsubstantiated


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
08/23/2024 and conducted by Evaluator Vincent Moleski
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240823101614
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: 142DATE:
01/16/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jennell ReveraTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Resident suffered injuries due to staff neglect
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, observation and record review. LPA Moleski interviewed Revera, 18 staff members (S1-S18), and one resident (R1).

LPA Moleski reviewed an incident report log for R1 dating between 5/22/24 and 10/19/24. On 5/22, R1 was using their wheelchair as a walker, causing R1 to lose their balance and fall. R1 did not hit their head but had some bruising on their left hand and right leg and some redness on their back. On 7/28, R1 suffered a fall which was captured on camera. R1 tried to sit in their wheelchair, but missed and fell on their left side. R1 had no apparent injuries at the time. However, on 7/30, a staff member observed some bruising on R1's left hip. [continued on 9099-C]
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
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 2
Control Number 27-AS-20240823101614
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: 01/16/2025
NARRATIVE
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Another staff member observed this same bruising on R1's left hip on 8/1. On 8/6 at 3:07 a.m., R1 was trying to use their wheelchair as a walker in the hallway, and while a staff member (S18) attempted to redirect R1, R1 stood up and lost balance. R1 "gradually fell down as their hand was holding into the railing," according to S18’s note. R1 did not hit their head, but felt pain in their left arm. R1 suffered a skin tear on their elbow. First aid was provided. A few hours later, at 6:57 p.m., S8 noted R1 had a "big purple bruise on their neck." S8 made a second note at 8:48 p.m., noting that the bruise was bigger and R1 was feeling pain in their left arm. On 8/10, S15 observed "a lot of bruises" on R1's neck down to their left breast, and a bruise on their left hip. Ongoing progress notes for R1 also describe the appearance of bruises on R1's neck and chest between 8/6 and 8/10. On 8/18, R1 suffered an unwitnessed fall while attempting to transfer from bed to their wheelchair. R1 was sent to the hospital. LPA Moleski reviewed an incident report for R1's fall on 8/18/24. According to the incident report, R1 was attempting to transfer from bed to their wheelchair when R1 fell, and later complained of hip pain. R1 was admitted to a hospital for a hip fracture, and was transferred to skilled nursing afterward, per the incident report. LPA Moleski reviewed video footage of this fall, and observed that staff promptly responded to R1.

None of the 18 staff members interviewed had observed caregivers of this facility committing any acts of abuse or any acts of neglect resulting in injuries to any residents. In an interview with S18, the caregiver present for R1’s fall on 8/6/24, S18 said that R1 did not hit their neck, face, chest, or head, and had no explanation for the bruises later observed on R1. Several other staff members observed the bruises on R1’s neck described in the notes from 8/6/24, but none were aware of the precise cause of the injury. None of the 18 staff members interviewed voiced any significant concerns for R1’s care at this facility. In an interview, R1 said they were well taken care of at this facility. Assessments from prior to R1's hospitalization indicate R1 was able to independently use their walker and transfer themselves.

The department has determined the following as it relates to the allegations that a resident suffered injuries due to staff neglect:

Based on interviews, observation and record review, the above allegation is UNSUBSTANTIATED, which means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No deficiencies were cited regarding the above allegation. 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: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
LIC9099 (FAS) - (06/04)
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