342700064-6-22-2023-27-AS-LKIG-CTQTKZ-20230714144846

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700064
Report Date: 06/22/2023
Date Signed: 06/22/2023 02:00:10 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/22/2023 and conducted by Evaluator Michael Bilger

COMPLAINT CONTROL NUMBER: 27-AS-20230522140746

FACILITY NAME:	GRAMERCY COURT		FACILITY NUMBER:	342700064
ADMINISTRATOR:	CYSEWSKI, TRISA		FACILITY TYPE:	740
ADDRESS:	2200 GRAMERCY DRIVE		TELEPHONE:	(916) 482-2200
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95825
CAPACITY:	85	CENSUS: 77	DATE:	06/22/2023
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Kendra Noonan		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Illegal Eviction

INVESTIGATION FINDINGS:

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On 6-22-23, at 10:30am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to continue investigation and deliver findings for the allegation noted above. LPA met with Administrator Kendra Noonan and explained the purpose of the visit. During this investigation, LPA interviewed Administrator and additional witness. LPA also reviewed facility file documentation pertaining to resident1 (R1) including physician’s report, admissions agreement, incident reports, resident appraisal, fall risk assessments, mini-mental exam, progress notes, and additional assessments conducted by facility staff.
Based on interviews and record reviews it was determined that R1 sustained a fall on 3-16-23 which resulted in hospitalization and eventual transfer to a local skilled nursing facility rehabilitation and treatment for bladder infection. It was further determined that R1's responsible party was attempting to be reamit R1 from skilled nursing but has not been re-admitted.

{Cont. on 9099C}

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20230522140746

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: GRAMERCY COURT	FACILITY NUMBER: 342700064
	VISIT DATE: 06/22/2023

NARRATIVE

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Based on additional interview and record review, it was determined that Administrator engaged in a conversation with R1’s responsible person and informed responsible person that facility will not be accepting R1 back, and discussed possible alternative placement due to multiple episodes of falling, bladder infection, cognitive impairment, and frequent use of call button. However, R1 and R1’s responsible person did not receive a formal written eviction letter prior to or after R1’s hospitalization outlining reasons for eviction per regulation and facility’s admission agreement. At this time, R1 has not been accepted by facility for re-admission. Based on additional record review, it was determined that R1 was assessed as high fall risk and severe cognitive impairment, as well as various behavioral episodes. Upon further record review and interview, it was determined that facility did not complete a re-appraisal per regulatory requirements related to eviction procedures and so inform the R1's responsible person.

As a result of this investigation, it is determined that facility did not follow regulatory guidelines for the eviction process. Therefore, this allegation is SUBSTANTIATED. Citation is issued under Title 22, Division 6. An exit interview was conducted with staff3 (S3). Administrator Kendra Noonan gave permission for S3 to sign in her absence at the time of this report delivery. A copy of this report was provided to S3. Appeal rights provided.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20230522140746

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: GRAMERCY COURT	FACILITY NUMBER: 342700064
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/22/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/26/2023 Section Cited CCR 87224(a)(4)	1 2 3 4 5 6 7	Eviction Procedures. (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required... (4) If, after admission, it is determined that the resident has a need not previously identified and a reappraisal has been conducted pursuant to Section 87463, and the licensee and the person who performs the reappraisal believe that the facility is not appropriate for the resident. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee or designee will read regulation 87224(a)(4) and submit a signed declaration of understanding to LPA by POC due date.
	8 9 10 11 12 13 14	Based on record review and interview, Licensee designee (Administrator) did not give a formal notice of eviction to R1 and R1's responsible person, and produce an accompanying reappraisal for R1 per regulatory guidelines. This posed a potential health, safety, and resident rights risk to residents in care.	8 9 10 11 12 13 14	Licensee will per regulatory guidelines submit a formal written notice of eviction to responsible party and Licensing department. Notice to be sent to LPA by POC due date.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

LIC9099 (FAS) - (06/04)

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