342700064-8-7-2026-27-AS-LRIS-DX2UZ7-20260817160105

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700064
Report Date: 08/07/2026
Date Signed: 08/07/2026 04:45:36 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
11/14/2025 and conducted by Evaluator Kimberly Viarella

COMPLAINT CONTROL NUMBER: 27-AS-20251114141632

FACILITY NAME:	GRAMERCY COURT		FACILITY NUMBER:	342700064
ADMINISTRATOR:	TONI JONES		FACILITY TYPE:	740
ADDRESS:	2200 GRAMERCY DRIVE		TELEPHONE:	(916) 482-2200
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95825
CAPACITY:	85	CENSUS: 82	DATE:	08/07/2026
		UNANNOUNCED	TIME BEGAN:	10:26 AM
MET WITH:	Janessa Reyes, Administrator		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff do not ensure call buttons are answered timely resulting in care needs of residents not being met.
Licensee does not ensure staff are provided adequate PPE supplies.
Licensee did not prevent an outbreak of an infectious disease.
Licensee did not ensure reporting requirements were followed.

INVESTIGATION FINDINGS:

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On 08/07/26, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to close a complaint investigation into the above allegations. LPA idenitified herself upon arrival, stated the purpose of the visit, and asked to meet with Designated Facility Administrator. LPA met with Janessa Reyes.

Regarding: Staff do not ensure call buttons are answered timely resulting in care needs of residents not being met.

On 12/18/25, LPA spoke to S4 who who stated that they have witnessed staff providing care for a resident, has no concerns with her care or other resident care states 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 pained. Based on interviews and observations the above allegation is

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2026

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 3

Control Number 27-AS-20251114141632

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: 08/07/2026

NARRATIVE

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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.

Regarding: Licensee does not ensure staff are provided adequate PPE supplies.

LPA interviewed 6 staff members 4 of the 6 felt that there was adequate PPE. 1 felt that there should be more gowns available for staff to use and 1 felt that there was not enough PPE. Based on a review of the information collected during these interviews, the Department found the above allegation to be 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.

Regarding: Licensee did not prevent an outbreak of an infectious disease.

The Administrator at the time of this complaint, Toni Jones, contacted Sacramento County Public Health regarding a number of residents exhibiting a rash and itchiness. This was done for transparency and to seek guidance. Jones had the washer and dryer serviced and also ordered a pest control to spray for common bugs and spiders. Jones also purchased a tea tree oil body wash for residents and increased the number of showers. Jones emailed this LPA with an update regarding the measures they were taking at the facility on 01/16/26. A training was conducted on 11/24/25 on skin conditions, including scabies. Any resident with a suspicious rash was sent out or the in-house would evaluate. When a resident had a suspicious rash, PPE was set up in front of their room for staff to use and they were isolated until the treatment period was completed.

LPA reviewed the medical records for R1, R2, R3 and R4. All were treated with medications that typically treat scabies, however, only one doctor indicated that the treatment was for scabies. No skin scraping test was completed to verify diagnosis. Reyes stated that in order to protect the residents of their community, they made sure that any resident exhibiting a suspicious rash and/or itching was evaluated, and that those residents' rooms received a deep cleaning and that all of their clothing was washed in hot water. Reyes stated they followed their infection control protocol. There was not a preponderance of evidence to establish whether there was an infectious disease. Based on the interviews above, most of the staff interviewed felt that they had the necessary PPE. Based on interviews and record reviews, the Department found the above allegation to be 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.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2026

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20251114141632

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: 08/07/2026

NARRATIVE

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Regarding: Licensee did not ensure reporting requirements were followed.

LPA interviewed the responsible party for R1 who stated "The facility did everything in a timely fashion in order to get my family member's skin condition treated. I was notified when they were sent out and why."
LPA reviewed the incident report for R4 faxed on 12/09/25 for a skin evaluation. The Administrator at the time, Toni Jones explained that their in-house doctor came to the facility to do skin evaluations for the others who were demonstrating suspicious skin concerns, and since they were not sent out to the ER for evaluation, an incident report was not sent to Community Care Licensing. LPA and current administrator, Janessa Reyes discussed best practices going forward with regard to reporting requirements. Based on interviews and record reviews, the Department found the above allegation to be 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.

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

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2026

LIC9099 (FAS) - (06/04)

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