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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005464
Report Date: 08/12/2025
Date Signed: 08/12/2025 12:08:34 PM

Document Has Been Signed on 08/12/2025 12:08 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:CARLTON PLAZA OF ELK GROVEFACILITY NUMBER:
347005464
ADMINISTRATOR/
DIRECTOR:		JENNELL REVERAFACILITY TYPE:
740
ADDRESS:6915 ELK GROVE BLVD.TELEPHONE:
(916) 714-2404
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 180CENSUS: 137DATE:
08/12/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Jennell ReveraTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Vincent Moleski and Regional Manager (RM) Stephenie Doub arrived unannounced to conduct a case management visit. LPA Moleski and RM Doub met with facility administrator Jennell Revera and explained the purpose of the visit.

LPA Moleski reviewed an incident report received by the Community Care Licensing Division (CCLD) on July 28, 2025. The incident report stated that a resident (R1) was taken to a medical appointment on July 22, 2025. R1 had been experiencing "scant bleeding and foul odor when urinating." The physician reported that five medication-releasing intravaginal rings were removed from the resident's vagina during the visit.

LPA Moleski and RM Doub reviewed a signed order from R1's physician dated April 7, 2023. R1 was ordered to have a new ring inserted every 90 days. The manufacturer of the intravaginal ring indicates on their product webpage that the devices should be removed after 90 days of use. Revera said there was no documentation to suggest that staff nurses were given initial training on the use of the devices. Staff nurses had been inserting the devices since July 2024, according to R1's medication administration records (MARs). LPA Moleski reviewed R1's MARs and observed that R1 was given four intravaginal rings by facility staff and one by skilled nursing staff between July 2024 and June 2025. Staff were trained on the use of intravaginal rings on July 24, 2025, after R1 had been seen by her physician. The training material included instructions from the manufacturer of the ring, which specify that the rings should be removed after 90 days. This facility is hereby cited per 22 CCR Sections 87465(a)(4) and 87411(d). Because this deficiency resulted in a resident's injury and/or illness, an immediate civil penalty of $500 is hereby assessed. Appeal rights and a copy of this report were left with Revera.
NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Vincent Moleski
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2025
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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Document Has Been Signed on 08/12/2025 12:08 PM - It Cannot Be Edited


Created By: Vincent Moleski On 08/12/2025 at 10:42 AM
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
, 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: 08/12/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/13/2025
Section Cited
CCR
87465(a)(4)

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"(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
(4) The licensee shall assist residents with self-administered medications as needed." This requirement was not met as evidenced by:
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Licensee has already conducted a training regarding this product, dated July 24, 2025. This POC will be cleared.
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Based on record review and interview, a resident's medication was mismanaged, which poses an immediate health, safety, and/or personal rights risk.
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Type B
08/22/2025
Section Cited
CCR87411(d)

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"(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance:" This requirement was not met as evidenced by:
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Licensee agrees to provide a written plan regarding how and when training is conducted for LVNs regarding medical devices or interventions.
vincent.moleski@dss.ca.gov
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Based on record review and interview, staff nurses were not trained in the use of a medication-releasing intravaginal ring which they had been inserting for a resident, which poses a potential health, safety, and/or personal rights 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.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Vincent Moleski
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2025


LIC809 (FAS) - (06/04)
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