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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700064
Report Date: 08/02/2023
Date Signed: 08/02/2023 12:11:10 PM


Document Has Been Signed on 08/02/2023 12:11 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: 77DATE:
08/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Veronica MoralesTIME COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual inspection on 08/02/2023 at 8:30 AM. LPA met with Veronica Morales and stated the purpose of today’s visit. LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations.

The interim Administrator holds current certificate. The facility is licensed for 85 non-ambulatory residents, and has an approved hospice program for 15. There are currently 77 residents who reside at this facility.

LPA Martinez toured the facility with Veronica Morales on 08/02/2023 at 11:00 AM

The last fire inspection report was completed on April 12, 2023. The fire inspection is done every 6 months, and the next fire inspection will be completed in October of 2023. The fire inspection includes kitchen range hood, ansel, fire extinguishers, smoke and carbon detectors. The facility has a first aid kit. LPA inspected 3 resident bathroom sink water temperature. The water temperatures measured at: 115, 125, and 125 degrees. The water heater was adjusted during visit. LPA Martinez inspected 3 resident rooms, and they were furnished and in good repair. In addition, the facility has a food service company that creates the monthly menus, and has an adequate food supply. The facility has a common area for activities for both Assisted Living and Memory Care units. LPA Martinez reviewed 10 resident files, and all files were maintained and complete. LPA Martinez reviewed 5 employee files, and all files were complete. LPA Martinez audited one medication file. The medication was complete. There were no deficiencies cited at this annual inspection. An exit interview was conducted, and a copy of this report was provided to the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2023
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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