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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700064
Report Date: 07/13/2026
Date Signed: 07/13/2026 05:43:01 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
11/07/2025 and conducted by Evaluator Kimberly Viarella
COMPLAINT CONTROL NUMBER: 27-AS-20251107134505
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:
07/13/2026
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Janessa Reyes, AdministratorTIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Staff do not answer resident's call button in a timely manner.
Staff do not dispense medications as prescribed.
Staff do not treat resident with dignity.
Staff do not ensure that colostomy bags are properly discarded.
INVESTIGATION FINDINGS:
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On 07/13/26 Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver the findings of this complaint investigation. LPA identified herself upon arrival, stated the purpose of the visit and asked to meet wiht the Designated Facility Administrator. LPA met with Janessa Reyes and a brief meeting followed.

Allegation: Staff do not answer resident's call button in a timely manner.

On 12/18/25 LPA Michael Bilger spoke to S4 who stated that they have witnessed staff providing care for a resident, has no concerns with their own care or other residents' care, and stated that staff are providing “the best care they can.” LPA also observed that there was 1 med tech, 2 care givers, 1 resident care Director and 1 Wellness Care nurse available to provide care to 20 residents. Residents were well looked after and none appeared, worried, sad, or in pain. Based on interviews and observations the above allegation is unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2026
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 6
Control Number 27-AS-20251107134505
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: 07/13/2026
NARRATIVE
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The following deficiency, 87464(F)(2) was cited per California Code of Regulations, TITLE 22, DIVISION 6, CHAPTER 8 Article 8.

According to the California Code of Regulations Title 22, no other deficiencies were cited during today's visit, a copy of this report was provided and an exit interview was conducted with Reyes.


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

DATE: 07/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 27-AS-20251107134505
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: 07/13/2026
NARRATIVE
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Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Allegation: Staff do not dispense medications as prescribed

On 12/18/25, LPA Bilger conducted a review of medication log sheets and determined that medications were logged correctly and given as prescribed. Based on record review the above allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Allegation: Staff do not treat resident with dignity.

On 07/13/26, LPA interviewed the responsible parties for 3 residents who were living on the same hallway as R1, 1 resident living on that hallway at the time of this complaint, and 3 staff who were working at the time of this complaint. 6 out of 7 individuals interviewed stated that the staff treated all residents with dignity. One stated that they had not seen any evidence of a resident not being treated with dignity. Based on interviews, the above allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Allegation: Staff do not ensure that colostomy bags are properly discarded.



On 07/13/26, LPA interviewed the responsible parties for 3 residents who were living on the same hallway as R1, 1 resident living on that hallway at the time of this complaint (R4), and 4 staff who were working at the time of this complaint (S4-S7). LPA learned that R1's room was cleaned every day at approximately 9:00 AM by S4 when R1 would go to breakfast and then once again in the afternoon. S4 would take the trash out during both of those visits. Care givers would also remove trash upon request. It was noted by all staff and the resident interviewed, R4, that when R1 requested assistance, they expected immediate assistance and sometimes that was not possible as they were assisting other residents. R4 stated that they talked to R1 on more than one occasion about their demands, reminding R1 that staff had other residents to assist.

Out of the 7 interviews conducted, 1 responsible party (RP1) stated that they had seen bags of trash (which contained a colostomy bag) in R1's room. This LPA asked if they had used the call button to request that
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 6
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
11/07/2025 and conducted by Evaluator Kimberly Viarella
COMPLAINT CONTROL NUMBER: 27-AS-20251107134505

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:
07/13/2026
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Janessa Reyes, Administrator TIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Staff do not provide adequate laundry service.
INVESTIGATION FINDINGS:
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On 07/13/26 Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver the findings of this complaint investigation. LPA identified herself upon arrival, stated the purpose of the visit and asked to meet wiht the Designated Facility Administrator. LPA met with Janessa Reyes and a brief meeting followed.

Allegation: Staff do not provide adequate laundry service

On 11/14/26 CCIB received another complaint from another resident advocate who stated the resident was not receiving adequate laundry services. Resident’s POA corroborated that R2 was not receiving adequate laundry services. Based on interview with RP, resident advocate, R1 and POA of R2, the above allegation is substantiated.
The Department has concluded, based on the preponderance of the evidence obtained during this investigation, that the above is SUBSTANTIATED.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Citations on this Visit Report are Under Appeal!

Control Number 27-AS-20251107134505
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: 07/13/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type B
07/20/2026
Section Cited
CCR
87464(F)(2)
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(f) Basic services shall at a minimum include:
(2) Safe and healthful living accommodations and services, as specified in Section 87307, Personal Accommodations and Services.

The above requirement was not met as evidenced by:
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Administrator stated that they will submit an audit of all the individuals who require daily cleaning/laundry services due to high incontinent care needs to Licensing at CCLASCPSacramentoSouthRO@dss.ca.govby the close of business on 07/31/26.
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Based on interview with RP, resident advocate, R1 and POA of R2, the above allegation is substantiated. This posed a potential threat to the health safety and personal rights of 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: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 27-AS-20251107134505
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: 07/13/2026
NARRATIVE
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that staff dispose of the trash, and if so, how long did it take before they arrived? RP1 replied that they did not, they "took care of it." Based on interviews, the above allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

This LPA did observe during her visit with R1 on 11/26/25, that the trash receptacle in R1's bathroom did not have a lid as required for solid wastes, This deficiency will be cited per the California Code of Regulations, Title 22, 87303(f)(3) during a future case management visit.

During that case management visit, this LPA will also address the fact that a reappraisal should have been conducted when staff first realized that R1 did not have the dexterity in their hands to care for their own ostomy bag resulting in the bag being dropped on the floor or placed in the trash still open and not knotted closed.

According to the California Code of Regulations Title 22, no other deficiencies were cited during today's visit, a copy of this report was provided and an exit interview was conducted with Reyes.



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

DATE: 07/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 6