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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700064
Report Date: 01/16/2026
Date Signed: 01/16/2026 03:47:41 PM

Unsubstantiated


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
12/16/2025 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20251216161036
FACILITY NAME:GRAMERCY COURTFACILITY NUMBER:
342700064
ADMINISTRATOR:TONI JONESFACILITY TYPE:
740
ADDRESS:2200 GRAMERCY DRIVETELEPHONE:
(916) 482-2200
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:85CENSUS: 84DATE:
01/16/2026
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Joanne BlackburnTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Licensee not ensuring that residents' care needs are being met
INVESTIGATION FINDINGS:
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On 1-16-2026 at 2:30pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver findings for the allegation noted above. LPA met with wellness nurse Joanne Blackburn and explained the purpose of the visit. Administrator made aware by facility staff of LPA's visit and purpose. During this investigation, LPA conducted interviews with four staff members and one resident in care. LPA also reviewed facility file documentation including service plans, medication log sheets, physician’s orders, physician’s report, hospice documentation, and progress notes pertaining to resident1 (R1). Additionally, LPA conducted a facility observation on 12-18-2025.
Allegation: Licensee not ensuring that residents’ care needs are met. LPA conducted interviews and record reviews as noted above. This allegation references R1 and the presence of blisters and rashes throughout R1’s body as well as a presence of pain. Based on these interviews and record reviews it was revealed that R1 experienced blisters and rashes on various parts of R1’s body within the review period of October 2025 to December 2025. It was further revealed that R1 began receiving hospice services on or about 11-17-2025 which included continued treatment of blisters and rashes as well as pain management. {Cont.on 9099C}
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2026
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 2
Control Number 27-AS-20251216161036
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: 01/16/2026
NARRATIVE
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A review of hospice documentation revealed consistent follow up of R1’s condition and updates to physician orders as well as communication with facility staff. Facility progress notes further revealed on-going follow up of R1’s blisters and rashes and other conditions as well as acknowledgement of all physician orders. A review of medication log sheets indicates R1 was assisted with prescribed medications consistently which included topical creams and oral medications to address skin conditions and pain. Interviews conducted did not reveal any corroborated evidence of staff not ensuring care needs for residents in care. An observation by LPA conducted on 12-18-2025 revealed staff attending to various resident needs in a timely and appropriate manner. As a result, although R1 has experienced skin and other conditions during R1’s stay at facility, there is not a preponderance of evidence to conclude staff is not ensuring care needs are met, therefore the above allegation is UNSUBSTANTIATED. A finding of unsubstantiated means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.
An exit interview was conducted with wellness nurse and a copy of this report was provided. LIC 811 and Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2