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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700064
Report Date: 03/19/2024
Date Signed: 07/31/2024 12:10:01 PM


Document Has Been Signed on 07/31/2024 12:10 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: DATE:
03/19/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Veronica MoralesTIME COMPLETED:
12:30 PM
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On 3/19/24 at 10:00am, Department representatives Kevin Gould (LPA), Kim Viarella (LPA), Czarrina Camilon-Lee (LPM), Stephen Richardson (LPM) and Stephenie Doub (RM) met with representatives from Gramercy Court to discuss recent compliance issues at the facility and the steps the facility is taking to address the department's concerns. Representing Gramercy Court is Dan Bushnell - Regional Director, Veronica Morales - Administrator, Nima Pourfathi - Administrator (Gramercy skilled nursing).

Department and facility representatives recent concerns of non-compliance including reporting requirements. The department discussed concerns with reporting incidents that pose a danger to residents in a timely manner consistent with title 22 regulations. The facility has conducted reporting training and training on mandated reporting. The facility agreed to conduct training on mandated reporting and reporting requirements every six months.

Department and facility representatives discussed re-evaluation and the facility following their own plan of operations and admission agreements regarding evictions when a resident may pose a danger to themselves or others. Facility representatives discussed steps taken including a new management team at Gramercy Court and the inclusion of facility nurse to assist in the evaluation and appraisal of residents prior to admission and regularly when present in the facility or there is a change in condition.

The department also discussed the facility one on one supervision policy and requested an updated written policy be provided to the department. Additionally, the facility has increased licensee oversight with the regional director being on site monthly to ensure compliance. The department will also assist in expediting the administrator certificate for Veronica Morales.

Report Continued on LIC 9099C
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: GRAMERCY COURT
FACILITY NUMBER: 342700064
VISIT DATE: 03/19/2024
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In summary the facility agreed to the following and will provide the department of documentation of policy and procedure changes.
  1. Updated one on one supervision policy
  1. Documentation of most recent reporting requirements training and mandated reporter training to be completed every six months.
  2. Increased oversight of the facility by licensee as regional director will be on site once per month to ensure compliance.
  3. The department has offered TSP support and the facility voluntarily accepted. Department will make TSP referral.
Per California Code of Regulations, Title 22 there were no deficiencies cited during today's meeting. An exit interview was conducted, and a copy of this report was mailed to the facility for signature.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024
LIC809 (FAS) - (06/04)
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