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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700064
Report Date: 08/28/2024
Date Signed: 08/29/2024 02:53:20 PM


Document Has Been Signed on 08/29/2024 02:53 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 08/29/2024 02:47 PM

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

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This is an amended report to correct a typo observed after LPA Gould final printed report.

On 8/28/24 at 9:00am Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced Case Management inspection at Gramercy Court to address and incident report from 4/1/23 where it was disclosed a resident had sexually harassed another resident in the facility. LPA met with administrator Veronica Morales and together discussed the reported incident and obtained additional information.

LPA Gould reviewed three resident files and requested copies of resident appraisals, physician reports, ID and emergency information, admission agreement, any incident reports/SOC 341 and any progress notes for the identified residents on our about April 2023.

LPA Gould conducted interviews with two staff member and one resident. LPA attempted to interview another resident but was enjoying a preferred activity and did not with to converse with LPA at the time of inspection.

Based on the interviews and information gathered during today's inspection, the department will conduct additional interviews and file review before making a determination regarding the reported incident.

Exit interview was conducted and a copy of this report was left a the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024
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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