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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002933
Report Date: 03/14/2023
Date Signed: 03/14/2023 04:30:29 PM


Document Has Been Signed on 03/14/2023 04:30 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
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



FACILITY NAME:GREY MANORFACILITY NUMBER:
345002933
ADMINISTRATOR:RAMOS, KARLFACILITY TYPE:
740
ADDRESS:5216 NORTH AVETELEPHONE:
(916) 934-4234
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 6DATE:
03/14/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Noel EstilloreTIME COMPLETED:
04:50 PM
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Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a post-licensing inspection utilizing the post-licensing inspection tool. LPA met with Assistant Administrator (Asst Admin), Noel Estillore, and explained the purpose of the visit. Today's census is 6 with (3) resident on hospice services. Facility is licensed for capacity of 6 and hospice waiver of 6.

LPA and Asst Admin conducted a tour together to ensure the health and safety of residents in care. In areas toured included but not limited to the common areas, kitchen, dining room, staff restroom, resident private bedrooms and bathrooms.

During the tour, LPA observed (2) caregivers present wearing mask. LPA observed (2) residents in the common area watching television, (3) residents alone in their private rooms and (1) resident to be in their private room with a nurse. LPA observed the kitchen to have sharps and medication to be locked and secured. LPA observed the facility to have 2+ days of perishable and 7+ days of nonperishable foods. LPA observed fire extinguisher to be last serviced on 10/14/2022. LPA and Asst Admin completed the post-licensing inspection tool and facility was found to be in compliance.

LPA conducted a file review of (1) out of (6) residents files and (2) personnel files.

As a result of today's inspection, no deficiencies cited.

Exit interview conducted and a copy of the report was left at the facility.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2023
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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