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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700064
Report Date: 07/21/2022
Date Signed: 07/21/2022 04:57:26 PM


Document Has Been Signed on 07/21/2022 04:57 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: 68DATE:
07/21/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:55 PM
MET WITH:Trisa CysewkiTIME COMPLETED:
05:05 PM
NARRATIVE
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On 7/21/22 at 3:55pm Licensing Program Analyst (LPA) Chris Hopkins arrived at Gramercy Court and conducted an unannounced case management visit. LPA met with Administrator Trisa Cysewski and stated the purpose of this visit.

LPA inquired about an incident that the facility reported on 7/20/22. This incident happened on 7/9/22 and wasn't reported to CCLD until 7/20/22. A clipbooard registry staff member witnessed resident 1 (R1) in resident 2 (R2) bathroom. While R2 was sitting on the toilet R1 stuck his fingers inside R2 private parts and the registry staff member walked in on this happening. Once the staff member walked in R1 immediately stopped and left the room. Due to this incident, Administrator has put a 1:1 care in place for R1 24/7. Administrator states that there is enough staff for this to happen, since they are using registry staff. There is also a police report on this incident.

A deficiency was cited on the 809D page as a result of today's visit per CCR Title 22. Exit interview held and a copy of the report and appeal rights provided to the administrator.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 07/21/2022 04:57 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: GRAMERCY COURT
FACILITY NUMBER: 342700064

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
07/22/2022
Section Cited
CCR
87211(a)(D)

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87211(a)(D) Reporting Requirements: A written report shall be submitted to the licensing agency ... Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not met as evidenced by:
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Administrator has agreed to conduct an in-service training regarding mandating reporting, reporting requirements, and elder abuse. Date of scheduled training is due by POC due date of 7/22/22 end of business day
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Licensee did not ensure that the report was sent within 7 days of the serious incident occuring which poses an immediate health, safety and personal rights risk to residents in care.
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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.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2022
LIC809 (FAS) - (06/04)
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