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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700064
Report Date: 08/11/2021
Date Signed: 08/11/2021 04:10:37 PM

Document Has Been Signed on 08/11/2021 04:10 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:GRAMERCY COURTFACILITY NUMBER:
342700064
ADMINISTRATOR:CYSEWSKI, TRISAFACILITY TYPE:
740
ADDRESS:2200 GRAMERCY DRIVETELEPHONE:
(916) 482-2200
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY: 85CENSUS: 70DATE:
08/11/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Trisa CyseskiTIME COMPLETED:
04:15 PM
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Licensing Program Analysts (LPA) Ashley Boothe conducted a case management visit to the facility on 08/11/2021 for the purpose of delivering an Order to Licensee/Facility of Immediate Exclusion From Facility for all facilities for Staff one (S1).

LPA met with Administrator and explained the purpose of visit. S1 is excluded as a result of actions related to a licensed facility. S1 was present in the facility during today's visit. LPA observed Administrator contact S1 and escort them off the facility property. S1 has been removed from the schedule after today's date.

LPA handed the Order to Licensee/Facility of Immediate Exclusion From Facility and explained that S1 cannot come to the facility and cannot be allowed to work, be present and/or live in a CCL licensed facility or have contact with clients in any residential facility or child day care licensed by the California Department of Social Services.

Exit interview conducted, a copy of this report provided on this date. A signature on these forms acknowledges receipt of these forms.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Ashley Boothe
LICENSING EVALUATOR SIGNATURE: DATE: 08/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/11/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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