<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002933
Report Date: 10/05/2023
Date Signed: 10/05/2023 11:54:47 AM


Document Has Been Signed on 10/05/2023 11:54 AM - 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: DATE:
10/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Kassie Howell and Karl RamosTIME COMPLETED:
12:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 10/5/2023, Licensing Program Analysts (LPAs) Cassie Yang and Cheyenne Ratajczak arrived unannounced at the facility to conduct a Required 1- year annual inspection utilizing the care tool. LPAs met with caregiver, Kassie Howell, who contacted Administrator, Karl Ramos, who arrived to the facility shortly afterwards.

LPAs and Caregiver conducted a tour of the interior and exterior of the facility. Areas toured included but not limited to: six private residents room, two bathroom, kitchen, backyard, storage area, and the common areas. LPAs observed three residents in the common area watching television and two residents in their private rooms. LPAs observed the facility to have 2+ days of perishable and 7+ days of nonperishable foods. LPAs observed the laundry door to be unlock. LPAs observed cleaning solutions to be stored in the laundry room. LPAs informed caregiver although facility is in the middle of laundry, door shall be locked at all times.

LPAs conducted a file review of personnel and residents records. LPAs observed one staff file to be incomplete with the required documents. LPAs provided facility with a copy of California Code Regulation 87412 Personnel Records. LPAs additionally provided facility with a list of the required documents for staff files.

LPAs completed the full care tool and deficiencies was observed. Please see LIC 809-D.

Exit interview conducted and a copy of the report and appeal rights was provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 10/05/2023 11:54 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: GREY MANOR
FACILITY NUMBER: 345002933

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(c)(1)(B)(2)
87412 Personnel Records
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation.
(1) The following staff training and orientation shall be documented:
(B) For staff who provide direct care to residents with dementia in a facility in which the licensee advertises dementia special care, programming, and/or environments, the licensee shall document the following:
2. The in-service training received as specified in Section 87707(a)(2). This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on file review, the licensee did not comply with the section cited above as LPAs observed one personnel file to be incomplete without the required annual trainings which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2023
Plan of Correction
1
2
3
4
Licensee will provided LPA Yang of the LIC 500 with proof of required trainings completed for all staff. Please provide the plan of correction requested documents to LPA Yang via email by October 31, 2023 5PM.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2