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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347005464
Report Date: 10/09/2025
Date Signed: 10/09/2025 12:08:13 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
10/03/2025 and conducted by Evaluator Vincent Moleski
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20251003122158
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: 133DATE:
10/09/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jennell ReveraTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Staff are not administering medication(s) to resident in care as prescribed.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Vincent Moleski and Triel Lindstrom arrived unannounced to open this complaint. LPA Moleski met with facility administrator Jennell Revera and explained the purpose of the visit.

This investigation consisted of record review and interviews. LPA Moleski interviewed Revera and two staff members (S1-S2).

In an interview, the facility's medication manager (S1) admitted that there had been a medication error for a resident (R1). S1 said that R1 had not been receiving a medication used to treat Parkinson's disease for several days due to an error in transcribing the prescription order into the facility's medication administration records (MARs). S1 said that R1 missed four daily doses of the medication between September 18 and September 25. [continued on 9099-C]
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025
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 3
Control Number 27-AS-20251003122158
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: 10/09/2025
NARRATIVE
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LPA Moleski reviewed R1's MARs. LPA Moleski observed that R1 had been taking the medications four times daily between September 13 and 17. R1 received one dose on the morning of September 18, at which point the medication was marked discontinued in R1's MARs. The medication was started again at 3 p.m. on September 25, and R1 continued to receive their medications as prescribed for the rest of the month.

LPA Moleski reviewed a fax sent to R1's prescriber dated 9/29/25 reporting the error. The fax stated that R1 received an order to increase a different order for the same medication on 9/18/25. "However, the order was not transcribed correctly," the fax read." As a result, the existing order ... was inadvertently discontinued. This led to [the medication] being missed from 9/18/2025 at 10:00 a.m. until 9/25/2025 at 12:00 p.m."

In an interview, S2 admitted to incorrectly transcribing the order. LPA Moleski reviewed fax and email records and observed that no incident report was received by the Community Care Licensing Division (CCLD) regarding this error. S2 said no report was sent to CCLD. 22 CCR Section 87211(a)(1)(D) requires that licensees report "any incident which threatens the welfare, safety or health of any resident..." This reporting error will be addressed in a separate case management report.

The department has determined the following as it relates to the allegation that staff are not administering medication(s) to a resident in care as prescribed:

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 87465(a)(4). 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: 10/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20251003122158
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: 10/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/10/2025
Section Cited
CCR
87465(a)(4)
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"(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 agrees to notify LPA Moleski of a planned training date regarding medication order transcriptions by POC due date.
vincent.moleski@dss.ca.gov
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Based on interviews and record review, a resident (R1) did not receive their regularly prescribed medication for more than six days, which poses an immediate 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.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025
LIC9099 (FAS) - (06/04)
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