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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345002933
Report Date: 10/19/2023
Date Signed: 10/19/2023 04:02:17 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
04/12/2023 and conducted by Evaluator Cassie Yang
COMPLAINT CONTROL NUMBER: 59-AS-20230412145121
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:
10/19/2023
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Kassie HowellTIME COMPLETED:
12:40 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Licensee admitted resident without a medical assessment signed by a physician within one year.
Licensee prohibited resident from having visits.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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 Assistant Administrator, Kassie Howell, and explained the purpose of the visit.

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

At this time, the allegations listed above has been detemined as unfounded, as the alleged incident occured at a different facility. UNFOUNDED-means that the allegation is false, could not have happened, and/or is without a reasonable basis.

LPAs will open a new complaint to the correct facility.

Exit interview and acopy of the report and appeal rights provided.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
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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