Carlton Senior Living Orangevale.

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.

**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.

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.

**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.

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.

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.

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.

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.

**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.

***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.

**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.

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.

*** 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.