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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700064
Report Date: 08/08/2023
Date Signed: 08/08/2023 04:21:12 PM


Document Has Been Signed on 08/08/2023 04:21 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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



FACILITY NAME:GRAMERCY COURTFACILITY NUMBER:
342700064
ADMINISTRATOR:CYSEWSKI, TRISAFACILITY TYPE:
740
ADDRESS:2200 GRAMERCY DRIVETELEPHONE:
(916) 482-2200
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:85CENSUS: 77DATE:
08/08/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Veronica MoralesTIME COMPLETED:
04:40 PM
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On 8/8/2023, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct a case management visit. LPA met with Interim Administrator Veronica Morales and explained the purpose of the visit.

The purpose of today’s visit was to follow up on a concern learned through an incident report. According to the incident report, on 7/22/23 facility staff found resident R1 using a razor blade to cut her wrist. Facility staff also noticed that R1 attempted to use a nail clipper to pick open the skin. R1 was sent to Mercy General Hospital for further evaluation and treatment. R1 was discharged from the hospital on 7/27/23 and was placed on 1 hour check upon returning to the facility. Resident was assessed by resident’s primary care physician and prescribed a new medication. Based on staff interviews, facility was not made aware that R1 had a razor blade in their possession. R1’s responsible party was made aware to notify the facility of any items they brought in for the resident. Facility will ensure that R1 doesn’t have access to any sharps.

Per the California Code of Regulations, Title 22, no deficiencies were cited during this visit. An exit interview was held and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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