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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700064
Report Date: 12/27/2022
Date Signed: 12/27/2022 02:55:33 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/15/2022 and conducted by Evaluator Christopher Hopkins-Clarke
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220815164019
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: 66DATE:
12/27/2022
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Trisa CysewskiTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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-Resident was sexually abused while in care
-Facility does not have sufficient staff to meet the residents' needs
INVESTIGATION FINDINGS:
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On 12/27/22 at 2:00 PM, Licensing Program Analyst (LPA) Chris Hopkins conducted an unannounced facility visit in regards to a complaint investigation with the above allegations. LPA met with Administrator Trisa Cysewski and stated the purpose of this visit.

Regarding the allegation of Resident was sexually abused while in care, the Department found the following; based on interview and record review, it was determined that R1 did sexually abuse R2 while in care. R2 reported this allegation to staff and repeated this allegation during interview. R1 has been documented for inappropriate sexual behaviors since 2020.

Regarding the allegation of Facility does not have sufficient staff to meet the residents' needs, the Department found the following; based on interview and record review, it was determined that staff were assigned to provide 1:1 care for R1 temporarily. There was miscommunication and no staff were supervising R1. This is when R1 went into the room of R3 and sexually abused R3. Report continued on LIC9099-C...

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 27-AS-20220815164019
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 12/27/2022
NARRATIVE
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Due to R2 and R3 sustaining serious bodily injury, the violation warrants civil penalty assessments. At this time, the civil penalty assessments are under review, and a civil penalty determination is pending by the Department. Once civil penalty assessments have been determined, an LPA will return at a future date to assess the civil penalties. As a result of this investigation, the Department finds this allegation to be substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency cited on the LIC 9099-D, per Title 22 Regulations and appeals rights given.

Exit interview was conducted, and copy of this report was provided to facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20220815164019
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
12/28/2022
Section Cited
CCR
87468.1(a)(3)
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87468.1(a)(3) Personal Rights of Residents in All Facilities (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights:(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature...This requirement was not as evidenced by:
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Administrator has agreed to do a thorough Pre-Assessment on all new residents and report immediately of any behavorial concerns. All staff have concluded their training on mandating reporting. Administrator will give copies of In-service training by 12/28/22.
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Based on interview, record review, and observation, the Licensee did not ensure residents were protected from R1's sexual inappropriate behavior and touching. This poses an immediate health and safety risk to residents in care.
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Deficiency Dismissed
Type A
12/28/2022
Section Cited
HSC
1569.2(c)
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1569.2(c) "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with taking medications, money management, or personal care. This requirement was not met as evidenced by:
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Administrator has given verbal instruction to staff that they are not allowed to go on break without their replacement being there. Also before going on break staff are to notify Med-Tech on duty that they are going on break. Administrator has agreed to do an In-Service training stating this, due by 12/28/22.
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Based on interview and record review, the Licensee did not ensure R1 was being properly supervised. This poses an immediate health and safety 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: 12/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3