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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306000295
Report Date: 09/22/2026
Date Signed: 09/22/2026 08:33:24 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/04/2026 and conducted by Evaluator RoseMarie Ruppert
COMPLAINT CONTROL NUMBER: 22-AS-20260504161046
FACILITY NAME:KARLTON RESIDENTIAL CARE CENTERFACILITY NUMBER:
306000295
ADMINISTRATOR:ELENA WEINERFACILITY TYPE:
740
ADDRESS:3615 WEST BALL RD.TELEPHONE:
(714) 236-1170
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:76CENSUS: 54DATE:
09/22/2026
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Elena Weiner, AdministratorTIME COMPLETED:
08:45 AM
ALLEGATION(S):
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Resident sustained multiple skin lesions and rib fractures due to neglect and lack of supervision.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rose Ruppert conducted an unannounced visit to deliver findings on an investigation completed by the Department. LPA was greeted and granted entry into the facility by Matthew Weiner and met with Elena Weiner, Administrator and explained the purpose of the visit.

During the course of the investigation, the Department interviewed staff and witnesses; and subpoenaed and reviewed hospital medical records. The Department also reviewed documents for Resident #1 (R1) and obtained a resident and staff roster. The investigation revealed the following:

Resident #1 (R1) is ninety years old and was admitted to the facility on December 21, 2023. Per Physician report dated March 10, 2025, R1 had a diagnosis of Major Neurocognitive Disorder due to unspecified disease; unspecified Dementia. Physician report further assessed R1 was non-ambulatory and required supervision for self-care needs and activities of daily living.
(Continued on LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2026
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 22-AS-20260504161046
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: KARLTON RESIDENTIAL CARE CENTER
FACILITY NUMBER: 306000295
VISIT DATE: 09/22/2026
NARRATIVE
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(Continued from LIC 9099)

On February 26, 2026, R1 went to Urgent Care due to scattered rashes on various parts of the body. Per Unusual Incident Report, R1 was assessed by the physician, a treatment was prescribed and staff continued to monitor R1’s skin integrity. On May 2, 2026, R1 was transported to Kaiser Hospital via ambulance, due to lethargy, and was admitted to the hospital. Upon admission, R1 had a small scratch on the left cheek and on the left forearm.

Hospital records from May 2, 2026, evaluated R1 with diagnoses of Pleural Effusion Hypoxemia, Shortness of breath and Major Neurocognitive Disorder due to Alzheimer’s Disease. Chest x-rays on this date revealed there was an acute mildly displaced right lateral third rib fracture. R1 remained in the hospital due to aspiration pneumonia and was discharged on May 7, 2026.

On May 26, 2026, the Department interviewed Resident #1 (R1) at their new Residential Care Facility for the Elderly (RCFE). R1 could not recall when they moved from Karlton Residential Care Center (KRCC) to their current location, or when they were in the hospital. R1 did not remember having any falls but recalled having a rash at KRCC. R1 denied any neglect or lack of supervision by the KRCC facility caregivers. Two of two additional residents interviewed stated that staff were attentive to their needs and that care was being provided. Three of three residents denied the allegation of neglect and lack of supervision.

The Department interviewed Witness #1 (W1) who is familiar with R1. The witness stated that the facility notified them of R1’s rash issues and that they were monitoring the rash. W1 stated that R1 has dementia and did not have any complaints or problems with the care R1 received. W1 stated that they, as well as the facility, were not aware of any falls and that the rib fracture was discovered from the last hospital visit when R1 had shortness of breath. W1 denied the allegation that R1 sustained multiple skin lesions and rib fractures due to neglect and lack of supervision.

Additionally, four of four staff were interviewed regarding R1’s skin lesions and rib fractures. Four of four staff were unaware of R1 having a fall and sustaining a rib fracture. Staff were informed by the hospital on May 2, 2026, regarding the rib fracture. Four of four staff denied the allegation that the skin lesions and rib fractures were sustained due to staff neglect and lack of supervision.

(Continued on LIC 9099-C1)

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20260504161046
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: KARLTON RESIDENTIAL CARE CENTER
FACILITY NUMBER: 306000295
VISIT DATE: 09/22/2026
NARRATIVE
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(Continued from LIC 9099-C)

Based on the Department’s records review, interviews and observations the allegation that Resident sustained multiple skin lesions and rib fractures due to neglect and lack of supervision is Unsubstantiated. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Administrator Elena Weiner, and a copy of this report and LIC 811 was left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3