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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700064
Report Date: 07/15/2026
Date Signed: 07/15/2026 11:57:45 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
11/13/2025 and conducted by Evaluator Kimberly Viarella
COMPLAINT CONTROL NUMBER: 27-AS-20251113084659
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:
07/15/2026
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Janessa Reyes, AdministratorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Licensee did not provide adequate laundry service.
Licensee did not ensure that the resident’s room was kept clean and sanitary.
Licensee did not ensure that the responsible party was provided resident's medical records in a timely manner.
INVESTIGATION FINDINGS:
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On 07/15/26, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver the findings for this complaint investigation. LPA identified herself upon arrival, stated the purpose of the visit, and asked to meet with the Designated Facility Administrator, Janessa Reyes. The two met to review the allegations and findings.

Allegation: Licensee did not provide adequate laundry service.

On 11/07/25, a resident advocate, fulfilling their requirements as a mandated reporter, filed a complaint that their client, resident (R2), was not receiving adequate laundry service. Based on reports from R1 and R2, residents, the resident advocate, and R2's Power of Attorney (POA), the Department concluded the above allegation SUBSTANTIATED. This deficiency was cited on complaint control # 27-AS-20251107134505, dated 11/07/25, therefore the Department will not be reissuing this citation as it is within the same investigation window.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2026
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 7
Control Number 27-AS-20251113084659
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: 07/15/2026
NARRATIVE
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Allegation: Licensee did not ensure that the resident’s room was kept clean and sanitary.

LPA reviewed photographs of R1's room that were taken on Friday, 12/05/25. LPA observed a photo (#1) of a document showing that R1's room was scheduled to be cleaned twice a week on Wednesdays and Saturdays. Another photo (#2) was of a full laundry basket in R1's closet. In a third photo (#3), this LPA observed a rolled up adult brief on the floor, a terry cloth towel in a bedside trash can, and what appeared to be feces on the carpet and several brown stains in the carpet by the side of the bed. There were also crumpled tissues and other scraps of paper and trash on the floor. Another photo (#4) was taken in the bathroom and was of the toilet bowl which was stained on the rim with smeared feces and urine. In another photo (#5), it can be observed that there was blue tape along the entire corner and side (roughly 8-10 inches) of the countertop securing it in place. A separate case management will be conducted to address the fixture being in disrepair. The Department has concluded, based on the preponderance of the evidence obtained during this investigation, that the above deficiency was SUBSTANTIATED. This deficiency has been cited on the LIC 9099D page.

Allegation: Licensee did not ensure that the responsible party was provided resident's medical records in a timely manner.

The POA for R1 requested R1's medical information in writing on 10/27/25. The facility did not provide the documents until 11/04/25, 8 days later. This was a violation of Health & Safety Code 1569.269(a)(21) which states that residents, or their valid power of attorney, have a right to prompt access to records; copies provided within 2 business days. The Department has concluded, based on the preponderance of the evidence obtained during this investigation, that the above is SUBSTANTIATED. This deficiency has been cited on the LIC 9099D page.

LPA conducted a tour of the facility prior to this exit interview and observed residents in the dining areas preparing for lunch and an outside agency facilitating fellowship.

According to the California Code of Regulations, Title 22, no other deficiencies were observed or cited during today's visit, a copy of this report was provided along with APPEAL RIGHTS. An exit interview was conducted with Administrator Reyes, and a case management visit will also take place today to address any deficiencies observed during the course of this investigation.

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

DATE: 07/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 27-AS-20251113084659
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: 07/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/31/2026
Section Cited
CCR
87468.1(a)(2)
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Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities... (2) To be accorded safe, healthful and comfortable accommodation, furnishings and equipment. The above requirement was not met when:
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Administrator will have the Resident Care Coordinator Pam Chore track the room inspections she does and turn it to licensing by 07/31/26 to CCLASCPSacramentoSoutRO@dss.ca.gov
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Based on a review of the 5 photos received by this LPA, it was observed that the carpet had brown stains and that there was feces and an adult brief on the floor along with crumbled tissues and trash. The posed a potential risk 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: 07/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 27-AS-20251113084659
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: 07/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/31/2026
Section Cited
HSC
1569.269(21)
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1569.269 (21) Enumerated rights; severability -To have prompt access... their records... Photocopied records shall be promptly provided, not to exceed two business days... The above requirement was not met when:
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Administrator stated that they will conduct a training with staff on document requests made responsible parties/families/POAs and Conservators.
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Based on interviews with the POA, the advocate and S1, the records were requested in writing twice and were not delivered until 11/04/25. This posed a potential threat to the health, safety and personal rights of residents in care.
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* This page was amended to include the information on the left. Nothing else was added or deleted.
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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: Lisa Rios
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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
11/13/2025 and conducted by Evaluator Kimberly Viarella
COMPLAINT CONTROL NUMBER: 27-AS-20251113084659

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:
07/15/2026
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Janessa Reyes, AdministratorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Due to a lack of supervision,resident sustained multiple falls while in care.
Licensee did not ensure that a fall prevention plan was implemented to ensure resident's safety while in care.
Licensee did not ensure that there was enough staff to meet the needs of the resident.
Facility failed to meet residents needs which resulted in death.
Licensee did not ensure that staff did not administer unauthorized medication to resident while in care.
INVESTIGATION FINDINGS:
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On 07/15/26, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver the findings for this complaint investigation. LPA identified herself upon arrival, stated the purpose of the visit, and asked to meet with the Designated Facility Administrator, Janessa Reyes. The two met to review the allegations and findings.

Allegation: Due to a lack of supervision, resident sustained multiple falls while in care.

On 03/03/26 IB investigator Murrow interviewed 4 residents (R3- R6) regarding falls. R3 stated that they had gone to the hospital several times but that it’s never the facility staff’s fault. One time they tripped and fell, they were able to get themselves up right away and didn’t need to go to the hospital. R4 stated that the staff check on them frequently even though they are so independent. They were asked if there was ever a time they needed help and didn’t receive it and they stated, “No, they always help”. R5 stated that staff is always there to help them and has not witnessed any issues with the other residents and their care. R6 stated that
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 27-AS-20251113084659
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: 07/15/2026
NARRATIVE
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staff will assist them with anything they may need. R6 also stated that staff really go out of their way to assist the other residents. 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 was 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: Licensee did not ensure that a fall prevention plan was implemented to ensure
resident's safety while in care.

A review of R1's file was conducted. On 09/15/24 it was noted on R1’s care Plan that R1 was a risk for falls. The facility implemented that staff will encourage R1 to stay in common areas, encourage participation in activities, ensure R1 is wearing appropriate fitting clothes and shoes. On 07/22/25, R1 sustained a fall. The following fall plan was implemented: Staff will evaluate R1 before moving to check for range of motion, conduct frequent checks, monitor for three days after a fall occurs, report any changes in condition. Staff will evaluate location of fall to identify any factors which could have contributed to the fall. Staff will encourage R1 to attend activities and promote exercise. Based on a review of records, it was determined that the facility did put a fall plan in place for R1 and the above allegation wad 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: Licensee did not ensure that there was enough staff to meet the needs of the residents.

Based on interviews with 4 residents, observations made by LPA and IB investigators at times of visits on: 08/07/25, 11/07/25, 11/13/25, 11/14/25, 11/24/25, 11/25/25, 12/16/25, 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: Facility failed to meet residents needs which resulted in death.



On 03/03/26 records were reviewed from Sutter Hospital. On 09/01/25, R1 was sent to hospital due to a fall. X-rays were taken and no sign of injury was identified, so R1 was sent back to the facility. On 09/20/25, R1
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 27-AS-20251113084659
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: 07/15/2026
NARRATIVE
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complained of pain and was sent back to the hospital. This time a CT was conducted that showed signs of a closed fracture. Based on the records reviewed, the facility obtained medical attention each time R1 exhibited pain and cared for the resident based on the hospital tests conducted. The above allegation was 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: Licensee did not ensure that staff did not administer unauthorized medication to resident while in care.

According to the Power of Attorney for Medical (POA) for R1 on 09/03/24, they contacted R1's primary care physician's office. The POA told the physician assistant (PA) to immediately take R1 off of Seroquel. According to The POA, the PA agreed except for a PM dose at 8:00PM, if needed. LPA reviewed the orders faxed over by the physician's office on 09/08/24 which stated, "Take quetiapine (the generic for the above mentioned medication) 25mg twice daily (in the morning 8AM and in the evening 8PM)". LPA reviewed the Electronic Medication Record (EMAR) for R1 for that time period and it showed that the facility followed the written orders provided by the doctor's office, as they are required to do according to the California Code of Regulations, Title 22. Based on this review of records, the above allegation was 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.

LPA conducted a tour of the facility prior to this exit interview and observed residents in the dining areas preparing for lunch and an outside agency facilitating fellowship.

According to the California Code of Regulations, Title 22, no other deficiencies were observed or cited during this visit. A copy of this report was provided, along with APPEAL RIGHTS and an exit interview was conducted with Administrator Reyes.

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

DATE: 07/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2026
LIC9099 (FAS) - (06/04)
Page: 7 of 7