StarlynnCare

California · Orangevale

Carlton Senior Living Orangevale

RCFE

A Residential Care Facility for the Elderly (RCFE) is a non-medical residential care home licensed by California CDSS under Health & Safety Code §1560. Residents receive assistance with daily living activities such as bathing, dressing, meals, and medication management in a home-like setting. RCFEs are not hospitals or skilled nursing facilities — they do not provide round-the-clock medical care.

8773 Oak Rd · Orangevale, 95662

Quick facts

Licensed beds136
Memory careYes
Last inspectionMar 2026
Last citationMar 2026
Operated byCarlton Senior Living Llc;carlton Operations Et Al

Inspection comparison

Updated May 1, 2026

Compared to 89 California RCFE facilities of similar size, over the last 36 months.

Source: California Department of Social Services, Community Care Licensing Division. View raw inspection records →

Peer comparison

Percentile vs 89 similar California CA / rcfe_general / xl beds facilities · higher = better

Severity
44th

Weighted citations per bed

Repeats
100th

Repeat deficiencies as share of total

Frequency
70th

Deficiencies per inspection

Tick mark at 50% = peer median

Citation severity over time

↑ worsening

Weighted severity score per month · 24 months

Jun 24peer medianMay 26

Weighted score (24mo)

23

Last citation

Mar 26

Finding distribution

3 total · 36 months

Scope × Severity (CMS A–L)

IsolatedPatternWidespreadJKLG2HID1EFABCSev 4 · IJSev 3Sev 2Sev 1

View inspections & citations

The rules that apply to this facility

California Title 22 requirements for this facility, with the specific regulation and a suggested question for each.Rules this facility has been cited for are shown first.

What must this facility report to the state — and how fast?Cited Oct 202522 CCR §87211 / WIC §15630
  • ImmediateElopement, fire, epidemic outbreak, or poisoningImmediately
  • 2 hoursAbuse with serious bodily injury2-hour phone report + 2-hour written report — to the California Department of Social Services (CDSS), Adult Protective Services, and law enforcement
  • 24 hrsAbuse without serious bodily injuryWithin 24 hours
  • Next dayDeath of a residentPhone by next working day; written within 7 days
  • Next dayInjury requiring medical treatment beyond first aidPhone by next working day; written within 7 days
  • WrittenBankruptcy, foreclosure, eviction, or utility shutoff noticeWritten notice to CDSS and residents — $100/day penalty (max $2,000) for failure

Your enforcement lever:Incidents that aren't reported on time are themselves a separate violation. If you believe a reportable event wasn't filed, you can submit a complaint directly to the California Department of Social Services (CDSS).

What dementia-care training must staff complete?22 CCR §87705 / HSC §1569.625

Because this facility markets dementia or Alzheimer's care, state law mandates higher training standards:

  • 12 hours initial dementia training — 6 hours before a staff member works independently with residents, 6 more within the first 4 weeks.
  • 8 hours annual dementia in-service — required every year thereafter.
  • Administrator CE — the administrator must include 8 hours of dementia-specific continuing education in every 2-year recertification cycle.

Training must cover individualized care plans, behavioral expressions, appropriate supervision, and the facility's dementia care philosophy.

Ask on tour: Ask how dementia training records are kept — families may request documentation.

How many staff must be on duty overnight?22 CCR §87415

Based on 136 licensed beds:

One awake caregiver on duty, one on-call caregiver physically on premises, and one additional on-call caregiver.

Violation pattern to watch for:A facility that documents a staff member as "on call" but with that person physically off-site — when the law requires on-premises presence — is in violation of this section.

Ask on tour: Ask the facility to walk you through their overnight staffing plan and confirm whether on-call staff are on premises or off-site.

What health conditions can this facility legally accept or refuse?22 CCR §87612–87615

Restricted — allowed with physician order + care plan

  • Supplemental oxygen
  • Insulin and injectable medications
  • Indwelling or intermittent catheters
  • Colostomy / ileostomy
  • Stage 1 and Stage 2 pressure injuries
  • Wound care (non-complex)
  • Incontinence
  • Contractures

Prohibited — facility must refuse or discharge

  • Stage 3 or Stage 4 pressure injuries
  • Feeding tubes (PEG, NG, or J-tube)
  • Tracheostomies
  • Active MRSA or communicable infections requiring isolation
  • 24-hour skilled nursing needs
  • Total ADL dependence with inability to communicate needs

A hospice waiver (HSC §1569.73) can allow continued care for residents on hospice who would otherwise fall into a prohibited category.

Ask on tour: Ask whether your loved one's specific care needs are restricted or prohibited, and what the facility's process is if needs change after admission.

How does CDSS enforce these rules?22 CCR §87755–87777 / HSC §1569.58
  1. 1Notice of DeficiencyWritten citation with a correction deadline. Facility must submit a Plan of Correction.
  2. 2Civil PenaltyStarts at $50/day for non-serious; $150/day for serious deficiencies — immediately, with no grace period. Repeats escalate to $150 first day + $50/day, then $1,000 first day + $100/day.
  3. 3Suspension of AdmissionsFacility cannot accept new residents until violations are corrected.
  4. 4Temporary Suspension or RevocationEmergency suspension for imminent danger; full revocation after administrative hearing.
  5. 5Exclusion OrderAdministrator and operator can be barred from all CDSS-licensed facilities — not just this one.

See how these rules have been applied to this specific facility:

View state inspection record and citations

Questions to ask on your tour

Based on Carlton Senior Living Orangevale's state inspection record.

  1. The facility has 2 serious citations on file across all inspections — can you provide your corrective-action plan for each cited item, and show families any documentation of remediation steps taken?

  2. 11 complaints are on file with CDSS — were any substantiated, and what remediation did the facility take in response to substantiated findings?

  3. The facility has 3 deficiencies on file — can you provide the deficiency notices and corrective-action documentation for each cited item?

  4. The March 26, 2026 inspection is the most recent on file — can you walk families through the findings from that visit and any follow-up actions the facility has taken since then?

State records

California Dept. of Social Services · Community Care Licensing
License number
345002805
License type
RESIDENTIAL CARE ELDERLY
License status
LICENSED
License expires
Not yet indexed
Licensed beds
136
Operator
Carlton Senior Living Llc;carlton Operations Et Al

Inspections & citations

24

reports on file

3

total deficiencies

2

Type A (actual harm)

Other visitMarch 26, 2026
No deficiencies

Inspector: Talwinder Bains

ComplaintMarch 26, 2026Type A
1 deficiency

Plain-language summary

On February 21, 2026, a staff member at the facility gave a resident the wrong medications—Buspiram, Donepezil, and Vitamin B12 that were meant for another resident—though the resident was reported to be doing fine afterward. The facility notified the resident's doctor and family immediately. State inspectors determined this was a medication administration error that posed an immediate health and safety risk, cited the facility for violating regulations, and assessed a $250 penalty because the facility had committed the same violation within the previous 12 months.

View full inspector notes

On 3/26/26, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility to conduct a Case Management visit regarding an incident that occurred on 02/21/26 . LPA met with Administrator Emanuel Dirar and explained the reason for visit. Incident Report, IR (LIC 624) submitted by facility on 02/21/26 to CCL stated that resident, R1 was given wrong morning medications on 02/21/26. IR indicated that on 2/21/2026 at approximately 9:00 AM, staff made a medication error and administered medications intended for another resident to R1. The medications administered by error were Buspirone 5 mg tablet, Donepezil 10 mg tablet and Vitamin B12 1000 mcg tablet. Staff notified immediately of the facility’s management regarding the medication error. Facility notified R1’s physician, responsible party and other required agencies regarding this medication error. LPA was notified that R1 was doing fine at the facility as of today. Based on incident report, staff interviews and medication record review from the facility, It was determined that facility administered wrong medications to R1 which poses a immediate health and safety risks to residents in care. Deficiencies are cited on LIC809D, pursuant to California Code of Regulations, Title 22, Section 80075(b)(5)(B) and documented on the attached LIC809D. Civil penalties may be assessed if facility does not comply with POC requirements which were issued today. Immediate Civil penalty of $250.00 was assessed on LIC421FC today due to repeat violation of the same regulation within 12 months. The report was reviewed, appeal rights and a copy of this report was left at the facility.

Type ACCR §80075(b)(5)(B)

Regulation

80075 -Health Related Services (b)(5)(B) - Once ordered by the physician the medication is given according to the physician's directions.... This requirement was not met as evidenced by:

Inspector finding

Based on incident report, staff interviews and medication record review from the facility, It was determined that facility administered wrong medications to R1 which poses a immediate health and safety risks to residents in care.

Other visitMarch 26, 2026
No deficiencies

Plain-language summary

On March 26, 2026, the state conducted a follow-up visit to investigate a resident's death and determine whether the facility was responsible. The investigation found that the resident died from natural causes and that the facility was not negligent, so no violations were cited.

View full inspector notes

On 3/26/26, Licensing Program Analyst (LPA) Talwinder Bains arrived unannounced to conduct a case management visit. LPA met with Administrator,Emanuel Dirar and explained purpose of inspection. The Department conducted a case management visit to follow up on the death of R1. The department conducted an investigation which found that R1’s death was determined to be from natural causes. Based on the information obtained, R1’s death was not due to negligent from the facility therefore no citations will be issued due to this incident. Exit interview was conducted and a copy of the report was provided.

ComplaintMarch 26, 2026
No deficiencies

Inspector: Talwinder Bains

Plain-language summary

A complaint investigation looked into allegations that staff were not providing adequate meal service, feeding assistance, incontinence care, catheter care, and safe transfer assistance. Investigators interviewed residents and staff, reviewed facility records, and observed operations; they found no evidence supporting any of these allegations—residents reported satisfaction with meals and care, staff were properly trained and equipped, and adequate staffing was in place to meet residents' needs.

View full inspector notes

**Report continued from 9099..... Allegation- Staff do not ensure residents receive meal services. Staff do not ensure residents receive feeding assistance. UNFOUNDED An investigation has been conducted regarding the above allegations. LPA observed the facility food supply as well as interviewed four residents regarding the food service. Based on observation and interviews, the facility keeps the required amount of food supply in the facility. Additionally, four residents’ interviews indicated that residents are satisfied with the food service at the facility and there were no concerns. During the facility tour, LPA observed the food menu for residents in the common area. Three staff interviews reflected that residents were satisfied with meal services and residents can choose alternatives if they do not like the food items served in the regular menu. Furthermore, staff delivered food trays to those residents who were unable to go to the dining room and assist residents with feeding who require assistance without any problems. Based on this information, these allegations are UNFOUNDED. Allegation- Staff do not ensure residents incontinence care needs are being met. Staff do not ensure residents catheter care is being provided in a timely matter. UNFOUNDED Based on interviews conducted with three staff and four residents, as well as the review of facility records, including charting notes, staff schedules, and resident records, it has been determined that the facility is meeting the resident's ADL (Activities of Daily Living) needs as required. The interviews with both staff and residents indicated that care was being provided in a professional manner, and no concerns were expressed. Based on these investigations, it has been concluded that the facility has enough staff to meet the residents' needs. Staff and residents interviews did not reflect any concern regarding resident’s toileting and any other care needs including catheter care. Based on this information, these allegations are UNFOUNDED. Allegation- Staff do not ensure residents receive adequate care with Hoyer transfers. UNFOUNDED Department interviewed three staff and four residents during complaint investigation. Department has reviewed facility records, including charting notes, staff schedule and resident records. Interviews and record review indicated that facility was following resident's physician's orders while transferring them. Residents and staff interviews indicated that facility has all transferring equipment's such as hoyer lift, sit to stand lift to transfer residents and all equipment's were in good working condition without any issues. Furthermore, staff get proper training in timely manner regarding safe transfer techniques for residents and can ask any questions from management in case they have any questions or issues to address in this area; therefore, the above allegation is found to be UNFOUNDED. Based on the investigation, the preponderance of evidence standards has not been met. Therefore, the above all allegations is found to be UNFOUNDED . A finding that the allegations are unfounded means that the allegations are false, could not have happened, and/or is without a reasonable basis. Exit meeting conducted. A copy of this report has been provided to facility.

ComplaintFebruary 18, 2026
No deficiencies

Inspector: Talwinder Bains

Plain-language summary

A complaint alleged that staff mishandled residents' medications and did not follow doctor's orders. The investigation found no violation: staff were dispensing and administering medications on time according to physicians' orders, medication records were properly maintained without errors, and interviews with residents and staff confirmed no issues with medication management.

View full inspector notes

**Report continued from 9099..... Allegation- Staff mishandled a resident's medications. Staff did not follow the orders of a licensed physician. Based on the information provided, the investigation conducted by the department involved facility observations, record review, and interviews with staff and residents to investigate the complaint allegation. During these interviews with three (3) staff and three (3) residents, it was revealed that the facility dispensed all residents' medications on time and administered them as scheduled. Residents’ interviews indicated that staff were assisting them with their medications without any issues. Furthermore, a review of the records for the month of October 2025, indicated that the facility maintained proper logs for all medications in the centrally stored medication log, following physician's orders, and documenting them in the Medication Administration Record (MAR) without any errors. Staff interviews reflected that residents were given medications on time per their physician’s orders and there were no problems to address. R1’s hospice agency staff’s interviews indicated that there were no concerns regarding facility staff’s care or medications management related to R1. Based on these findings, this allegation is considered UNFOUNDED. Based on the investigation, the preponderance of evidence standards has not been met. Therefore, the above all allegations is found to be UNFOUNDED . A finding that the allegations are unfounded means that the allegations are false, could not have happened, and/or is without a reasonable basis. Exit meeting conducted. A copy of this report has been provided to facility.

ComplaintFebruary 18, 2026· Unsubstantiated
No deficiencies

Inspector: Talwinder Bains

Unsubstantiated — the California Department of Social Services (CDSS) investigated and did not find a violation.

Plain-language summary

A complaint alleged that a resident was inappropriately touching staff and that the facility failed to report incidents to the state. The Department investigated through record review and interviews with staff and residents and found no preponderance of evidence that either violation occurred; staff demonstrated they manage the resident's dementia-related behaviors appropriately through redirection and work with the resident's doctors and family on medication management. No citations were issued.

View full inspector notes

**Report continued from 9099-A...... Allegation - Resident inappropriately touching staff. Unsubstantiated The Department conducted records review, interviews with staff and residents to investigate this allegation. Residents and staff interviews reflected that resident, R1 has dementia with behaviors and R1 can be challenging sometimes with other individuals but staff are able to redirect them in safe and professional manner. Facility was continually working with R1s physicians and family to manage R1s behaviors with adjustments in their medications and other possible ways. Additionally, facility provided the required training's to staff regarding working with dementia residents on on-going basis and providing adequate staffing to take care of R1 and other residents. Based on this information, these allegations were found to be Unsubstantiated means Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation(s) occurred. Allegation - Facility is not meeting reporting requirements. Un substantiated. During complaint investigation, it was evaluated from record review and from staff interviews that facility was reporting all reportable incidents to department per Reporting Guidelines. It was learnt that there were incidents where resident, R1 was exhibiting challenging behaviors while staff were assisting them with their care needs, but staff were able to manage R1s care needs and able to redirect them when needed. There was insufficient information available regarding any incidents which were not reported to the department. Based on gathered information, this allegation was Unsubstantiated. A finding that the complaint allegations is UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No citations were issued today per CCR, Title 22 Regulations. Exit meeting conducted with administrator. A copy of this report has been provided to the facility.

Other visitFebruary 9, 2026· Unsubstantiated
No deficiencies

Inspector: Talwinder Bains

Unsubstantiated — the California Department of Social Services (CDSS) investigated and did not find a violation.

Other visitOctober 9, 2025Type B
1 deficiency

Plain-language summary

On October 9, 2025, a state licensing analyst visited the facility following a fall that occurred on September 11, 2025, in which a resident fractured a bone in their hand and was hospitalized. The resident later developed increased confusion and pain, was sent to a skilled nursing facility for rehabilitation per their doctor's orders, and did not return to the memory care facility. The facility failed to report this fall and injury to the state licensing agency in the timeframe required by law, and the state has issued a citation and required the facility to submit a plan to correct this reporting failure.

View full inspector notes

On 10/09/25, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility to conduct a Case Management visit regarding incidents related to resident, R1. LPA met with Administrator Emanuel Dirar and explained the reason for visit. Incident Report (LIC 624) submitted by facility on 09/27/25 to CCL stated that R1 had a fall on 9/11/25 was sent out to local hospital and diagnosed with fracture of 5th metacarpal. R1 returned to the facility presented with increased confusion and pain when standing. R1s primary care physician (PCP) advised for resident to be sent out for further evaluation on 9/19/25. Staff sent out R1 to hospital per PCP directions. It was learnt that R1 was sent to skilled nursing facility for rehab services per their PCP’s orders and R1 did not return to facility as of today. Based on incident report, staff interviews and record review from the facility, it was determined that facility did not report R1s fall and injury related incident from 09/11/25 in timely manner to CCL as required per Reporting Requirements. Based on gathered information, deficiencies are cited pursuant to California Code of Regulations, Title 22, Section 87211 and documented on the attached LIC809D. Civil penalties may be assessed if facility does not comply with POC requirements which were issued today. Exit interview was conducted, copy of the report and appeal rights were provided.

Type BCCR §87211(a)(1)(D)

Regulation

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including... (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence... (D) Any incident which threatens the welfare, safety or…

Inspector finding

Based on record review and staff interviews, it was concluded that resident, R1 had a fall with injury on 09/11/25 but an incident report was not submitted within required time frame , which poses a potential risk for residents in care.

Other visitOctober 9, 2025
No deficiencies

Plain-language summary

On October 9, 2025, the facility passed its required yearly inspection with no violations found. The inspector checked bedrooms, bathrooms, kitchen, emergency equipment, medication storage, and staff and resident records, and found everything in compliance with regulations. The facility had adequate food supplies, proper water temperature, working smoke and carbon monoxide detectors, and completed fire drill logs.

View full inspector notes

On 10/09/25, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced to conduct a required 1 year inspection utilizing the care tool. LPA met with Administrator Emanuel Dirar and explained the purpose of the visit. LPA and Administrator conducted a tour of the interior and exterior of the facility. Areas toured include but not limited to residents bedrooms, kitchen, bathrooms, dining room, common areas, storage area, and laundry area. LPA observed required furniture, and lighting throughout the residents' bedrooms and facility. LPA observed food supplies of non-perishables for a minimum of seven (7) days and perishable foods for a minimum of two (2) days. Hot water temperature was measured at 116 degrees Fahrenheit , which is within the required range of 105 to 120 degrees. The temperature in the facility was 73-74 degrees. First aid kit was completed. LPA observed fire detectors and carbon monoxide detectors to be operable. LPA observed the fire extinguisher, located in common areas which were ready for emergency use. LPA reviewed fire and disaster drill logs, which are conducted quarterly. LPA observed required Licensing posters posted throughout the facility. LPA conducted a file review of five (5) staff and eight (8) residents records. Residents and staff records were found to be complete. Medications are centrally stored, locked, and were inaccessible to residents. No deficiencies were observed or cited from this inspection per Title 22 Regulations. Exit interview was conducted and copy of the report was left at the facility.

ComplaintAugust 28, 2025
No deficiencies

Inspector: Talwinder Bains

Plain-language summary

The state investigated three complaints about care and conditions at this facility: that staff failed to provide personal care and toileting help, that residents didn't receive clean linens and clothing, and that meal service was inadequate. Investigators interviewed staff and residents, reviewed records, and toured the facility and found no evidence supporting any of these complaints. All three allegations were found to be unfounded.

View full inspector notes

**Report continued from 9099.... Allegation- Staff failed to provide care to meet resident's care and toileting needs.-UNFOUNDED Based on interviews conducted with five staff and five residents, as well as the review of facility records, including charting notes, staff schedules, and resident records, it has been determined that the facility is meeting the resident's ADL (Activities of Daily Living) needs as required. The interviews with both staff and residents indicated that care was being provided in a professional manner, and no concerns were expressed. Based on these investigations, it has been concluded that the facility has enough staff to meet the residents' needs. During the department's visits, it was observed that the residents’ needs were being met. Based on the investigation, the allegation made against the facility is found to be UNFOUNDED. Allegation- Facility did not provide clean linens and clothing to resident.-UNFOUNDED The Department conducted record reviews, facility observations, five staff and five residents interviews to investigate complaint allegations. During the Department visit on 08/06/25, LPA Bains observed that the facility has adequate linen supplies and clothing for all residents. Staff interviews indicated that there was no linen shortage at the facility and things were fine with linen supplies and usage. Resident’s interviews did not indicate any concerns in this area and expressed their satisfaction with clean linen supplies. Based on this information, this allegation was found to be Unfounded. Allegation- Facility did not provide adequate meal service to resident.-UNFOUNDED An investigation has been conducted regarding the above allegations. LPA observed the facility food supply as well as interviewed four residents regarding the food service. Based on observation and interviews, the facility keeps the required amount of food supply in the facility. Additionally, five residents’ interviews indicated that residents are satisfied with the food service at the facility and feel that they have enough food to eat at every meal. During the facility tour, LPA observed the food menu for residents in the common area. Five staff interviews reflected that residents were satisfied with meal services and residents can choose alternatives if they do not like the food items served in the regular menu. Furthermore, staff delivered food trays to those residents who were unable to go to the dining room during mealtimes. Based on this information, this allegation is UNFOUNDED. Based on the investigation, the preponderance of evidence standards has not been met. Therefore, the above all allegations is found to be UNFOUNDED . A finding that the allegations are unfounded means that the allegations are false, could not have happened, and/or is without a reasonable basis. Exit meeting conducted. A copy of this report has been provided to facility.

ComplaintAugust 28, 2025
No deficiencies

Inspector: Talwinder Bains

Plain-language summary

A complaint investigation looked into three allegations: pest infestation, staff hand-washing practices, and kitchen cleanliness. The department found no evidence to support any of the complaints—pest control records and recent visits were documented, staff and residents confirmed proper hygiene practices, and tours of the facility and work records showed regular cleaning and maintenance throughout the building.

View full inspector notes

***Report continued from 9099...... Allegation- Staff are not properly addressing pest infestation in the facility.-UNFOUNDED Based on documents obtained and statements reviewed, the department determined that there was insufficient evidence that the facility is not kept free of pests. The facility representative stated that the pest control company comes in monthly, and more often as needed. The department reviewed Pest Control dates for the monthly visits for 2025 which did not indicate any concerns. It was stated that the Pest Control company just visited the facility over a week ago and sprayed the exterior and interior of the building. The pest control company is continuing to monitor any pest activity. Five (5) staff and five (5) residents were interviewed and stated they have not seen any pests at the facility. During the department visits, the facility was toured and there were no concerns that were noted about this area. Therefore, the above allegation is UNFOUNDED. Allegation- Staff are not practicing proper hand washing procedures. -UNFOUNDED The Department conducted record review, interviewed five residents and five staff members to investigate this allegation. Staff interviews reflected that facility are following infection control guidelines including proper hand washing and there were no issues to report. Resident’s interviews indicated that the facility was complaint with infection control guidelines, and they were satisfied with staff’s care at the facility. Staff interviews also reflected that staff were getting the required training and in-services per department’s directions for infection control and other required topics and there were no concerns. Based on these findings, this allegation is considered UNFOUNDED. Allegation- Facility kitchen is not kept clean and orderly. -UNFOUNDED The department toured the facility during the investigation which included resident’s rooms , bathrooms, kitchen, dining area and other areas in the facility and did not observe any concern regarding cleanliness. LPA reviewed documents pertinent to the investigation which indicated that residents’ rooms are being cleaned and maintained by staff. LPA reviewed work orders placed at the facility for maintenance like carpet and floor cleanings which indicated staff and maintenance teams were cleaning on a regular basis to keep the facility and resident rooms and other areas clean and sanitized. Five staff and five resident’s interviews did not reflect any concerns that the facility was not kept clean and orderly. Based on the information gathered, this allegation was found to be UNFOUNDED. Based on the investigation, the preponderance of evidence standards has not been met. Therefore, the above all allegations is found to be UNFOUNDED . A finding that the allegations are unfounded means that the allegations are false, could not have happened, and/or is without a reasonable basis. Exit meeting conducted. A copy of this report has been provided to facility.

InspectionAugust 6, 2025Type A
1 deficiency

Plain-language summary

On August 6, 2025, state inspectors investigated an incident from July 25, 2025 in which a staff member gave a resident the wrong insulin dose; the resident was taken to the hospital that day and returned to the facility after receiving medical care. The facility notified the resident's doctor and family, and took action with the staff member involved. Inspectors determined this medication error posed an immediate health and safety risk and cited the facility with a deficiency; the facility was ordered to correct this violation or face civil penalties.

View full inspector notes

On 08/06/25, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility to conduct a Case Management visit regarding an incident that occurred on 07/25/25. LPA met with Administrator, Emanuel Dirar and explained the reason for visit. Incident Report (LIC 624) submitted by facility on 08/04/25 to CCL stated that resident, R1 was sent to hospital on 07/25/25 , after R1 was given the wrong insulin dose by staff. The incident report indicated that R1 was given wrong insulin dose around 11AM on 07/25/25. Staff notified immediately of the facility’s management regarding the medication error and facility send out R1 to hospital to seek medical care. R1 came back to the facility on 07/25/25. Facility notified R1s physician and the responsible party regarding medication error. LPA was notified by administrator that the facility took appropriate action with staff regarding this incident according to the facility policy who was associated with this incident . Based on incident report, staff interviews and medication record review from the facility, It was determined that facility administered wrong medication to R1 which poses a immediate heath and safety risks to residents in care. Deficiencies are cited on LIC809D, pursuant to California Code of Regulations, Title 22, Section 80075(b)(5)(B) and documented on the attached LIC809D. Civil penalties may be assessed if facility does not comply with POC requirements which were issued today. The report was reviewed, appeal rights and a copy of this report was left at the facility.

Type ACCR §80075(b)(5)(B)

Regulation

80075 -Health Related Services (b)(5)(B) - Once ordered by the physician the medication is given according to the physician's directions.... This requirement was not met as evidenced by:

Inspector finding

Based on record review from the facility, it was observed that on 07/25/25, resident, R1 was given wrong insulin dose by staff which poses an immediate health and safety risk to residents in care.

Other visitApril 3, 2025
No deficiencies

Plain-language summary

On April 3, 2025, the state licensing program conducted a follow-up visit after the facility reported that a resident alleged a staff member was unprofessional and physically abusive on March 21, 2025; the resident was checked for injuries and none were found, and the staff member was placed on administrative leave while the facility investigated. The investigator interviewed residents and staff, requested additional documents, and found no violations of state regulations at that time. The case remained under review pending further information.

View full inspector notes

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 04/03/25 to do case management visit . LPA met with Administrator, Emanuel Dirar and explained the purpose of the visit. Incident for Resident, R1 - Department followed up on SOC 341 sent by facility on 04/02/25 stating resident (R1) reported to the management on 04/02/25 that staff, S1 were unprofessional and physically abusive to resident, R1 during morning shift on 03/21/25. Facility notified R1s physician, LTCO ,law enforcement and responsible party regarding this incident. Facility Nurse checked R1 for any injurers on 04/02/25 and none were present. SOC341 also indicating that during facility’s internal investigation, S1 denied any wrongdoings and provided their written statement. LPA learnt that S1 was on administrative leave at this time due to this incident. Department conducted interviews with four residents and three staff members during today's visit. LPA requested incident related documents and facility shall send all requested information via email by 04/07/25 (Monday) by 9AM. At this time, this incident is under review and department will do follow up if warranted. No citations were issued per Title 22 Regulations. Exit interview conducted and copy of the report left at facility.

InspectionMarch 27, 2025
No deficiencies

Plain-language summary

On March 27, 2025, the state conducted an unannounced case management visit following a report that two staff members were rough and verbally abusive to a resident during care on March 20, 2025. A nurse checked the resident for injuries the next day and found none; the two staff members denied the allegations, while the staff member who reported the incident resigned. The state interviewed the resident and staff, found no violations, and said the matter remains under review with possible follow-up if needed.

View full inspector notes

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 03/27/25 to do case management visit . LPA met with Executive Assistant, Ellaina Canady and explained the purpose of the visit. Incident for Resident, R1 - Department followed up on SOC 341 sent by facility on 03/25/25 stating staff (S1) reported to the management on 03/20/25 around 6 pm that S1 witnessed that staff S2 and S3 were rough and verbally abusive to resident, R1 while S2 and S3 were providing care to R1 during morning shift on 03/20/25. Facility notified R1s physician, LTCO and responsible party regarding this incident. Facility Nurse checked R1 for any injurers on 03/21/25 morning and none were present. SOC341 also indicating that during facility’s internal investigation, S2 ad S3 denied any wrongdoings and provided their written statements however S1 resigned from their position. Department conducted interviews with resident ,R1 and staff (S2,S3, S4) during today's visit. At this time, this incident is under review and department will do follow up if warranted. No citations were issued per Title 22 Regulations. Exit interview conducted and copy of the report left at facility.

Other visitNovember 12, 2024
No deficiencies

Inspector: Talwinder Bains

Plain-language summary

An annual inspection was conducted on November 12, 2024, during which staff records, resident medications, facility safety systems, food storage, and living areas were reviewed and found to meet all state requirements. No violations were cited.

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Licensing Program Analyst (LPA) Talwinder Bains arrived on 11/12/24 to conduct the annual inspection. LPA met with administrator, Miriam Faris and explained the purpose of today's visit. During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed medications of five (5) residents comparing with physician orders and find no errors. LPA reviewed five (5) residents and five (5) staff files and found all required documents. LPA and administrator toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, kitchen, and common areas and outside area. The food supply is within compliance, 2 days of perishable and 7 days worth of non-perishable food items. Grab bars were present at the toilet and in the shower. All exits were unobstructed. LPA checked the kitchen area for the ability to prepare and store food. Knives and Sharp objects found to be locked. LPA observed the area used for medication to be locked and inaccessible to residents. LPA observed smoke detectors and carbon monoxide detector at the care home are operational. Fire extinguishers were last serviced on 11/27/23 and were ready for emergency use. Hot water temperature was observed to be 110-112 degrees F, which is within the regulation range of 105-120 degree. Inside temperature was 72-74 degree F. Facility was clean and well organized. All required postings were observed. Facility is conducting quarterly fire and disaster drill as required. No deficiencies were observed or cited per Title 22, CCR Regulations during this visit. Exit interview conducted and copy of this report was provided to administrator.

ComplaintJuly 31, 2024
No deficiencies

Inspector: Talwinder Bains

Plain-language summary

A complaint investigation found that the facility did not violate its contract with a resident or fail to provide quality food. Investigators reviewed records, observed a meal service, and interviewed staff and residents, all of which confirmed the facility followed the resident's care plan and served quality meals with choices and alternatives available.

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**Report continued from 9099.... Allegation- Facility did not follow resident's contract. Facility did not issue a refund to a resident in care.-UNFOUNDED The Department conducted record review, facility’s observations, staff and resident’s interviews to investigate these allegations. Record review indicated that resident, R1 moved in to the facility on 05/09/24 and the admission agreement was signed by facility Administrator, Miriam Faris and R1s responsible party (RP) on 05/07/24. Per admission agreement, monthly charges were agreed at $6695/monthly. RP paid $5062.55 (prorated rate for May 2024) and full month payment of $6695 for June 2024. It was also noted that per signed admissions agreement, RP was required to provide a 30 days notice to move out of the facility. R1 moved out of the facility on 06/16/24. RP gave 30 days notice to facility on 06/20/24. Four (4) Staff interviews conducted on 07/18/24 indicated that R1s care needs were providing per their Needs and Service plan. From all this gathered information, it has been concluded that RP did not provide 30 days ‘move out’ notice for R1 per admission agreement, therefore the facility does not owe a refund to R1 and RP. Additionally, facility staff followed R1s care needs based on R1’s need and service plan. Based on all this information, these allegations were found to be UNFOUNDED. Allegation- Facility is serving food to residents that is not of quality. UNFOUNDED The Department conducted record review, facility’s observations, staff, and resident’s interviews to investigate these allegations. During facility observation on 07/18/24, it was observed during meal service that facility was providing quality food to residents and staff were supportive to resident’s dietary needs. Record review indicated that facility provides choice of different foods with daily menu and substitute /alternate items are also available during meals. Four (4) Staff interviews conducted on 07/18/24 indicated that facility was meets residents dietary needs and offer quality food on daily basis. Four (4) residents interviews conducted on 07/18/24 reflected that facility’s meal services were fine and they enjoy their daily meals. Residents expressed their satisfaction with quality of the food that is served and did not report any concerns. Based on gathered information, this allegation was found to be UNFOUNDED. Based on the investigation, the preponderance of evidence standards has not been met. Therefore, the above all allegations is found to be UNFOUNDED . A finding that the allegations are unfounded means that the allegations are false, could not have happened, and/or is without a reasonable basis. Exit meeting conducted. A copy of this report has been provided to facility.

InspectionJuly 31, 2024
No deficiencies

Inspector: Talwinder Bains

Plain-language summary

During a routine inspection on July 31, 2024, inspectors learned that the facility reported a missing bottle of Oxycodone (a narcotic pain medication) for a hospice resident on July 20, 2024, which was discovered during the evening medication count and reported to the sheriff's department and other required agencies. The facility conducted an internal investigation and search for the missing medication, and inspectors interviewed staff and requested related documents. No violations were cited during this visit.

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Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 07/31/2024 to conduct a case management visit and met with Executive Assistant, Ellaina Canady and explained the purpose of the visit. The facility submitted a completed Unusual Incident/Injury Report (LIC624) on/around 07/22/24 regarding 1 missing bottle out of 3 bottles of Oxycodone (narcotic) for resident, R1 (hospice care) during pm med count on 07/20/24. IR stated that, on 7/20/24 Med Manager notified ED that during PM narcotic count a bottle of oxycodone was missing for R1, Prior to 2pm count on 07/20/24, R1 had 3 bottles of oxycodone. Sacramento County Sheriff’s Department was notified on 07/22/24 regarding this incident. Facility also notified CCLD, R1s physician, responsible party, hospice agency and other agencies as required. Facility launched their internal investigation and did the through search for this missing medication. During today's visit LPA interviewed 2 staff members and requested documents related to incident which facility will send to LPA via email by 08/02/24. This case is under review and Department will follow up as warranted. No deficiencies were cited during today's visit. Exit interview conducted and copy of the report left at the facility.

ComplaintMay 29, 2024
No deficiencies

Inspector: Talwinder Bains

Plain-language summary

A complaint alleged that facility staff did not safeguard a resident's belongings. The investigation found this allegation to be unfounded—staff interviews, resident interviews, and facility records showed no issues with how the facility handles personal items, and the facility was able to locate the items mentioned in the complaint.

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***Report continued from 9099..... Allegation- Facility staff did not safeguard resident's belongings ---Unfounded The Department conducted (4) four staff (4) four residents’ interviews, facility’s observations, and record review to investigate this allegation. From the records review, it has been revealed that the facility has a record of some of R1’s personal belongings which is documented on the R1’s Inventory Form and located in R1’s facility file. R1 did not list anything in that form and refused to list their personal belongings upon admission dated 04/29/22. R1 was discharged from the facility on 01/09/24. During the department facility visit, facility was able to find some of the missing items for R1 as listed in the complaint. R1 was contacted to make arrangements to pick up items from facility. Four (4) Residents interviews indicated that there were no issues with their personal belongings and facility is safeguarding them. Four (4) Staff interviews indicated that they were no issues with resident’s personal belongings and staff assist residents if they were missing any items to locate them or report to their managers if needed. Based on all this information, this allegation is found to be Unfounded. Based on the investigation, the preponderance of evidence standards has not been met. Therefore, the above all allegations is found to be UNFOUNDED . A finding that the allegations are unfounded means that the allegations are false, could not have happened, and/or is without a reasonable basis. Exit meeting conducted. A copy of this report has been provided to facility.

ComplaintMarch 7, 2024· Unsubstantiated
No deficiencies

Inspector: Talwinder Bains

Unsubstantiated — the California Department of Social Services (CDSS) investigated and did not find a violation.

Plain-language summary

The state investigated a complaint that staff mishandled resident medications. The investigation found no evidence of medication mismanagement—staff interviews, resident interviews, facility records, and observations all confirmed that medications were being given on time and documented properly according to doctors' orders.

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**Report continued from 9099...... Allegation- Staff mismanaged resident medication. Based on the department's investigation, including facility observations, record review, and interviews with staff and residents, it has been concluded that the allegation made against the facility regarding medication administration is unsubstantiated. The interviews with both staff and residents indicated that medications were being given to resident, R1 on time, and the facility maintained proper logs and documentation for all medications according to physician's orders. Residents interviews confirmed that they were receiving their scheduled medications in a timely manner, and the staff were not mismanaging their medications. Therefore, the allegation is determined to be without basis or evidence and is therefore considered Unsubstantiated. A finding that the complaint allegations is UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No citations were issued today per CCR, Title 22 Regulations. . Exit meeting conducted with administrator. A copy of this report has been provided to the facility.

ComplaintOctober 17, 2023· Unsubstantiated
No deficiencies

Inspector: Talwinder Bains

Unsubstantiated — the California Department of Social Services (CDSS) investigated and did not find a violation.

Plain-language summary

An investigator looked into a complaint that a resident had unexplained injuries while at the facility. After reviewing medical records and interviewing staff, the investigator found that the injuries were caused by the resident's self-injury behavior related to advanced dementia and their medical condition, not by lack of care or supervision from facility staff, so the complaint was not substantiated.

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*** Report continued from 9099........ Allegation-- Resident sustained unexplained injuries while in care. LPA conducted interviews which included residents, administrator and facility staff. LPA also reviewed facility and medical records regarding R1. Record review and interviews indicated that R1 sustained unexplained injuries while in care. These injuries were partly explained by self-injury behavior on the part of R1, who has advanced dementia and R1s medical condition. Facility staff noticed wounds on R1s leg/shin around 08/09/23 and notified R1s doctor and responsible party (RP). EMS was called to seek medical treatment for R1 but R1 denied transport denied by R1s RP who wanted only first aid given at facility. Facility reached out to R1s primary care doctor multiple times regarding these wounds and had a virtual appointment on 08/22/23 and seen by dermatologist on 08/31/23. R1s doctor did not order any home health staff to take care of these wounds and ordered to be treated at facility by facility professional staff (nurses). Additionally, LPA found out that staff was using Hoyer Lyft with 2 persons assist to transfer R1 from bed to wheelchair as ordered by R1s doctor without any issues. From all this gathered information, it has been concluded that R1 sustained unexplained injuries while in care due to their medical condition and not due to lack of care and supervision by facility staff. Therefore, this allegation is UNSUBSTANTIATED. A finding that the complaint allegations is UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No citations were issued today. Exit meeting conducted. A copy of this report has been provided to the facility.

InspectionOctober 17, 2023
No deficiencies

Inspector: Talwinder Bains

Plain-language summary

This was a routine annual inspection on October 17, 2023, where the facility passed with no violations. The inspector reviewed resident and staff files, toured all areas including bedrooms, bathrooms, kitchen, and common spaces, and confirmed that safety features like locked medication storage, secured cleaning products, and working smoke and carbon monoxide detectors were all in place. The facility's food supply, water temperature, and overall cleanliness met requirements.

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Licensing Program Analyst (LPA) Talwinder Bains arrived on 10/17/23 to conduct the annual inspection. LPA met with Administrator, Amanda Smith who assisted LPA during today's inspection. During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed residents (4) and staff files (4). All residents (4) and Staff (4) files contained the required paperwork. Staff have current first aid and CPR training. Facility was clean. All required postings were observed. LPA and Amanda toured the facility together to ensure the health and safety of residents in care. The areas toured included residents rooms, bathrooms, kitchen, common areas and outside area. The food supply is within compliance, 2 days of perishable and 7 days worth of non-perishable food items. All exits were unobstructed. The administrator's certificate is current. LPA checked the kitchen area for the ability to prepare and store food. Knives and Sharp objects found to be locked . LPA observed cleaning products and other toxins to be locked away. LPA observed the area used for medication to be locked and inaccessible to residents. LPA observed smoke detectors and carbon monoxide detector at the care home are operational. Fire extinguisher is ready for emergency use and was last serviced on 12/28/22. Water temperature is within compliance (109 degree F) .Inside temperature was observed to be 75 degree F. In the areas toured, there were no health or safety violations were observed. No deficiencies were observed or cited during today's visit. Exit interview conducted. A copy of this report was printed and given to Amanda.

Other visitDecember 20, 2022
No deficiencies

Inspector: Talwinder Bains

Plain-language summary

An unannounced one-year inspection was conducted on December 20, 2022, focusing on infection control practices. The inspector toured the facility including bedrooms, bathrooms, common areas, kitchen, and medication room, and found no violations. The facility was in substantial compliance with all requirements.

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Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 12/20/2022 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Executive Director (ED) - Lindsey Feifert , and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, the daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA wore the following Personal Protective Equipment (PPE) during today's visit: N-95 mask. LPA and ED toured the facility to ensure the health and safety of residents in care. Areas toured include but are not limited to: bedrooms and bathrooms for residents, common areas, dining rooms, kitchen area, laundry room ,medication room and outdoor area. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and ED completed the infection control domain and facility was found to be in substantial compliance at this time. No deficiencies are being observed or cited as a result of today's inspection. Exit interview conducted and copy of report left at the facility.

Other visitNovember 4, 2021
No deficiencies

Inspector: DeAnna Williams-Lyons

Plain-language summary

This was a pre-licensing inspection of a 136-bed facility conducted on November 4, 2021. The inspector found the facility met all minimum requirements: the administrator's certificate was valid, emergency supplies and medications were properly stored, common areas and bedrooms were clean and appropriately furnished, and adequate food supplies were on hand. No violations were observed.

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On November 4, 2021, at 10:30am, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to conduct a Pre-licensing Inspection. LPA met with Lisa Schumann, Executive Director and explained purpose of the inspection. Prior to initiating the inspection LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and a mask was worn for Personal Protective Equipment (PPE). The facility is a single floor facility with a capacity of 136. LPA observed the following: Administrator certificate is valid, expiring 3/27/2023. First aid kit fully stocked and ready for emergency use. Fire extinguishers fully charged. Common areas were clean and in good repair. Bedrooms had required furniture and lighting. Facility has required (2) day perishable supply of food and (7) supply of non-perishable food. Medication was properly stored and locked away. At the time of this inspection, the facility is in compliance and meets the minimum requirements for Residential Care Facility for the Elderly. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations were observed during this visit. Application is pending further review. Exit interview conducted and a copy of this report given to Lisa Schumann

ComplaintOctober 13, 2021
No deficiencies

Inspector: Bethany Hunter

Plain-language summary

This was a change of ownership application review conducted by phone on October 13, 2021, in which the new owner and administrator confirmed they understand California regulations for operating this 136-bed facility for elderly residents with limited mobility. The inspector verified their identification and reviewed their knowledge of facility operations, staffing requirements, admission policies, emergency preparedness, and complaint reporting procedures. No violations were identified during this review.

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Facility Type: Residential Care Facility for Elderly Application Type: Change of Ownership Capacity: 136 non-ambulatory, of which 10 may be bedridden Census (if any clients in care): 52 COMP II Participants: Lisa Schumann Interview Method: Telephone interview On October 13, 2021, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readiness

Federal summary

CMS Care Compare

Not a CMS-certified facility

California RCFEs (residential care facilities for the elderly) are licensed by the state, not by CMS. CMS data only applies to skilled nursing facilities or to CCRCs that operate a licensed SNF wing.

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