345002933-10-5-2023-59-AS-LMUZ-CWRNGV-20231019102743

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 345002933
Report Date: 10/05/2023
Date Signed: 10/05/2023 01:42:06 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH 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
03/28/2023 and conducted by Evaluator Cassie Yang

COMPLAINT CONTROL NUMBER: 59-AS-20230328163330

FACILITY NAME:	GREY MANOR		FACILITY NUMBER:	345002933
ADMINISTRATOR:	RAMOS, KARL		FACILITY TYPE:	740
ADDRESS:	5216 NORTH AVE		TELEPHONE:	(916) 934-4234
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	6	CENSUS: 5	DATE:	10/05/2023
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Karl Ramos and Kassie Howell		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Residents are chemically restrained with medication
Facility staff not fingerprint-cleared
Staff are using drugs while on duty
Facility staff are abusing residents

INVESTIGATION FINDINGS:

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On 10/5/2023, Licensing Program Analysts (LPAs) Cassie Yang and Cheyenne Ratajczak arrived unannounced at the facility to deliver the findings of the allegations cited above. LPAs met with Administrator, Karl Ramos, and explained the purpose of the visit.

During this investigation, the Department conducted extensive interviews and file reviews.

The results of the investigation are as follows.

Please continue on LIC 9099-C...

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie Yang	TELEPHONE: 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.

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20230328163330

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 10/05/2023

NARRATIVE

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Allegation: Residents are chemically restrained with medication.
Based on interviews conducted with S1, S2 and Administrator, it revealed that residents are only administered medications that are physician ordered. Interviews and medication review revealed that five residents are prescribed Melatonin, four are scheduled medication and one is as needed medication. LPAs observed medications to be given as ordered and no errors for residents. Based on information obtained, LPAs finds the allegation to be UNFOUNDED-means that the allegation is false, could not have happened, and/or is without a reasonable basis.

Allegation: Facility staff not fingerprint- cleared.
Based on file review, LPAs reviewed staff files for (3) staff, including photo ID, and observed that all staff are fingerprinted cleared and associated to the facility. LPAs confirmed via Guardian that S1, S2 and Administrator are fingerprint cleared. Based on information obtained, LPAs finds the allegation to be UNFOUNDED- means that the allegation is false, could not have happened, and/or is without a reasonable basis.

Allegation: Staff are using drugs while on duty.
Based on interviews with staff and residents, it revealed there are no concerns and/or suspicions of staff using drugs while on duty. Based on observation, LPAs conducted a tour of staff room and no deficiencies observed. Based on information obtained, LPAs finds the allegation to be UNFOUNDED- means that the allegation is false, could not have happened, and/or is without a reasonable basis.

Allegation: Facility staff are abusing residents.
Based on interviews with staff and residents in care, it revealed residents do not have any concerns with staff. LPA Yang observed residents watching television during time of inspection on 4/6/2023. Interview with R1 and R2, staff are nice and accommodating to residents in care. Based on information obtained, LPAs finds the allegation to be UNFOUNDED- means that the allegation is false, could not have happened, and/or is without a reasonable basis.

Exit interview conducted. Copy of report and appeal rights was provided to Administrator.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie Yang	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

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