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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700064
Report Date: 12/17/2024
Date Signed: 06/07/2025 10:31:49 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/04/2024 and conducted by Evaluator Kimberly Viarella
COMPLAINT CONTROL NUMBER: 27-AS-20241204153321
FACILITY NAME:GRAMERCY COURTFACILITY NUMBER:
342700064
ADMINISTRATOR:VERONICA MORALESFACILITY TYPE:
740
ADDRESS:2200 GRAMERCY DRIVETELEPHONE:
(916) 482-2200
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:85CENSUS: 80DATE:
12/17/2024
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Toni JonesTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Staff did not ensure that resident was treated for a scabies infection.
INVESTIGATION FINDINGS:
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On 12/17/24 Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to continue a complaint investigation into the above allegation. LPA identified herself upon arrival, stated the purpose of the visit, and asked to meet with Designated Facility Administrator. LPA met with Designee, Toni Jones and a brief interview followed.

LPA conducted a document review and learned the following. R1 was sent to the hospital for a fall. While at the hospital, R1 was assessed by a dermatologist who determined that the rash R1 had on the lower half of R1's body was consistent with scabies. A topical medication was administered before R1 was discharged with additional medication to be administered by the facility.

LPA reviewed R1's care plan. On page 6 of the care plan for R1, it stated that R1 "had bladder incontinence. Resident refuses to wear underwear or adult briefs. Staff to toilet resident every 2 hours." This part of the plan was updated 09/07/24.




Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
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 4
Control Number 27-AS-20241204153321
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/17/2024
NARRATIVE
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LPA requested shower logs/sheets for 2 months. LPA was told that shower sheets were only kept for 1 month. LPA informed staff that the shower sheets were part of the residents' care and thus a part of their permanent file. The information does not need to be kept in their regular file, but should be stored and accessible if requested.

11/27/24 Shower sheet for R1 was completed by staff (S6) who wrote "yes" for observing a rash and a bruise but did not indicate where.

12/02/24 Shower sheet was completed by staff (S5) who checked "yes" for bruise and reddened area and put an "X" next to rash. There was also a note that the resident refused a shower.

12/04/24 Shower sheet was completed by staff (S6) who checked off that there was a bruise and a rash and that the skin was intact.

12/11/24 Shower sheet was completed by staff (S7) who wrote "Yes" for rash and reddened area and highlighted 4 areas on R1's upper and lower legs.

On 12/12/24, LPA interviewed R1 and R1 stated their legs were itchy. LPA suggested the nurse assess R1's legs. The nurse later reported to the LPA that R1's legs were covered in a rash and R1 was being sent out for further evaluation.

From 11/27/24 - 12/12/24, R1 received 3 showers.

During an interview with S3, this LPA learned that it was not standard practice to have the shower sheets reviewed and signed off by a Medication Technician, Care Coordinator, or Nurse to ensure that they were being completed thoroughly and that all showers and skin checks were being conducted as scheduled.

LPA reviewed hospital discharge notes dated 11/27/24. On page 1 it stated, "Found to have scabies; treated with..."

Based on the document review and the information gathered from interviews with S3 and S1, the standard for the preponderance of evidence has been met and the department found the allegation, "Staff did not ensure that resident was treated for a scabies infection," SUBSTANTIATED.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20241204153321
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/17/2024
NARRATIVE
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According to the California Code of Regulations, Title 22, this deficiency is cited on the LIC 9099D page.

No other deficiencies were observed or cited during todays' visit. A copy of this report was provided along with APPEAL Rights and an exit interview was conducted.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20241204153321
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/10/2025
Section Cited
CCR
87466
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Observation of the Resident:
The licensee shall ensure...residents are regularly observed for changes... and that appropriate assistance is provided... physical health...are observed, the licensee shall ensure...are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.
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Care Coordinators to document into Point and Click into "Health Notes" regarding the status of showers.
Nurse to conduct in-service reviewing skin check procedures and the protocol for communicating that a resident has had a change of condition.
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The above regulation was not met as evidenced by: Based on a review of hospital discharge paperwork and shower logs along with interviews with S3 and S1, R1 had a change of condition (the rash) and should have been sent to the hospital for evaluation. This posed an immediate health, safety, and personal rights risk to residents in care.
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The facility will submit signature sheets for the training (along with the name of the person/organization to conduct training). It will also send a screenshot of the PCC system to demonstrate this new process. All due to CCL by 1/10/25.
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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.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4