Gramercy Court

Type of visit: Required - 1 Year

On September 22, 2026, at 12:30PM, Licensing Program Analyst (LPA) Sulma Lopez arrived unannounced at the facility to conduct an annual required inspection. LPA Lopez met with Administrator (A1) Janessa Reyes and explained the purpose of today's visit. The Administrator holds current certificate #6074815740 and expires on February 5, 2027. The facility is licensed for (85) non-ambulatory residents. There are currently (81) residents who reside at this facility. The facility has an approved hospice waiver for (15). (11) out of the (15) hospice placements are occupied. At 1:00 PM, LPA conducted record reviews of (10) staff and (10) resident files. Staff files contained health screen records, TB test records, and job applications. Staff files were observed to contain initial onboarding training records. LPA observed the facility's on-going in service training records which indicated that staff training took place in January, March, February, April, May, July, and August 2026 for a total of 9 hours. LPA also reviewed the facility's online training transcripts for 6 out of 10 staff. Three (3) out of 6 records contained training from 2025, three (3) out of 6 records contained training records from 2026, one (1) of which only contained 1 hour of training. Resident files contained health screen reports, pre-placement appraisals, and emergency information. Records review of the resident files indicated that 3 out of 10 resident needs and services plans were current. A1 stated that the Facility Nurse conducts resident reappraisals every 90 days, and records are only updated if there is a change of condition. At 3:15PM, LPA toured the facility with A1. The facility was clean, safe, and in good repair. Continued... The LPA toured the common areas and observed residents playing with puzzles and cards. The facility kitchens were observed to be clean and free of hazards. The facility contained medication rooms in both buildings which remain locked and inaccessible to residents. Medications were stored in locked cabinets and locked rolling carts. The LPA toured the resident bedrooms and observed that they were clean and sanitary. The bedrooms contained furniture in good repair. The LPA observed smoke detectors were located on bedroom ceilings. The facility courtyards were free of hazards. The LPA observed an outdoor shaded seating area for resident use. LPA toured the facility's main kitchen. The kitchen contained 7 days worth of non-perishable food items and at least 2 days worth of perishable food supply. The facility temperature was 72 degrees. The hot water temperature was 110 degrees. The fire extinguishers were serviced annually on August 5, 2026. As a result of this annual inspection, technical violations were notated on the LIC 910 2(s). An exit interview was conducted, a copy of this report and LIC 9102(s) were provided to the facility.the state’s words, verbatim · CDSS document, Sep 22, 2026

Allegation investigated: Staff do not ensure call buttons are answered timely resulting in care needs of residents not being met. Licensee does not ensure staff are provided adequate PPE supplies. Licensee did not prevent an outbreak of an infectious disease. Licensee did not ensure reporting requirements were followed.

On 08/07/26, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to close a complaint investigation into the above allegations. LPA idenitified herself upon arrival, stated the purpose of the visit, and asked to meet with Designated Facility Administrator. LPA met with Janessa Reyes. Regarding: Staff do not ensure call buttons are answered timely resulting in care needs of residents not being met. On 12/18/25, LPA spoke to S4 who who stated that they have witnessed staff providing care for a resident, has no concerns with her care or other resident care states that staff are providing “the best care they can”. LPA also observed that there was 1 med tech, 2 care givers, 1 Resident Care Director and 1 Wellness Care Nurse available to provide care to 20 residents. Residents were well looked after and none appeared, worried, sad, or pained. Based on interviews and observations the above allegation is Unsubstantiated unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding: Licensee does not ensure staff are provided adequate PPE supplies. LPA interviewed 6 staff members 4 of the 6 felt that there was adequate PPE. 1 felt that there should be more gowns available for staff to use and 1 felt that there was not enough PPE. Based on a review of the information collected during these interviews, the Department found the above allegation to be unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding: Licensee did not prevent an outbreak of an infectious disease. The Administrator at the time of this complaint, Toni Jones, contacted Sacramento County Public Health regarding a number of residents exhibiting a rash and itchiness. This was done for transparency and to seek guidance. Jones had the washer and dryer serviced and also ordered a pest control to spray for common bugs and spiders. Jones also purchased a tea tree oil body wash for residents and increased the number of showers. Jones emailed this LPA with an update regarding the measures they were taking at the facility on 01/16/26. A training was conducted on 11/24/25 on skin conditions, including scabies. Any resident with a suspicious rash was sent out or the in-house would evaluate. When a resident had a suspicious rash, PPE was set up in front of their room for staff to use and they were isolated until the treatment period was completed. LPA reviewed the medical records for R1, R2, R3 and R4. All were treated with medications that typically treat scabies, however, only one doctor indicated that the treatment was for scabies. No skin scraping test was completed to verify diagnosis. Reyes stated that in order to protect the residents of their community, they made sure that any resident exhibiting a suspicious rash and/or itching was evaluated, and that those residents' rooms received a deep cleaning and that all of their clothing was washed in hot water. Reyes stated they followed their infection control protocol. There was not a preponderance of evidence to establish whether there was an infectious disease. Based on the interviews above, most of the staff interviewed felt that they had the necessary PPE. Based on interviews and record reviews, the Department found the above allegation to be unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding: Licensee did not ensure reporting requirements were followed. LPA interviewed the responsible party for R1 who stated "The facility did everything in a timely fashion in order to get my family member's skin condition treated. I was notified when they were sent out and why." LPA reviewed the incident report for R4 faxed on 12/09/25 for a skin evaluation. The Administrator at the time, Toni Jones explained that their in-house doctor came to the facility to do skin evaluations for the others who were demonstrating suspicious skin concerns, and since they were not sent out to the ER for evaluation, an incident report was not sent to Community Care Licensing. LPA and current administrator, Janessa Reyes discussed best practices going forward with regard to reporting requirements. Based on interviews and record reviews, the Department found the above allegation to be unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. According to the California Code of Regulations, Title 22, no deficiencies were observed or cited during today's visit. a copy of this report was provided, along with APPEAL RIGHTS, and an exit interview was conducted with Reyes.the state’s words, verbatim · CDSS document, Aug 7, 2026 · control 27-AS-20251114141632

Type of visit: Case Management - Other

On 7/27/2026, Licensing Program Analyst, (LPA) Kimberly Viarella made an unannounced visit to this facility to amend a report. LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator, Janessa Reyes. LPA explained to Reyes that the LPA amended the D page of the report for complaint investigation #27-AS-20251113084659 delivered on 07/15/26. This amendment did not change the deficiency or its plan of correction. LPA reviewed the report again with Reyes, collected the original and provided a new copy for their records. According to the California Code of Regulations, Title 22, no deficiencies were observed or cited during today's visit, a copy of this report was provided and an exit interview was conducted with Reyes.the state’s words, verbatim · CDSS document, Jul 27, 2026

Allegation investigated: Licensee did not provide adequate laundry service. Licensee did not ensure that the resident’s room was kept clean and sanitary. Licensee did not ensure that the responsible party was provided resident's medical records in a timely manner.

On 07/15/26, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver the findings for this complaint investigation. LPA identified herself upon arrival, stated the purpose of the visit, and asked to meet with the Designated Facility Administrator, Janessa Reyes. The two met to review the allegations and findings. Allegation: Licensee did not provide adequate laundry service. On 11/07/25, a resident advocate, fulfilling their requirements as a mandated reporter, filed a complaint that their client, resident (R2), was not receiving adequate laundry service. Based on reports from R1 and R2, residents, the resident advocate, and R2's Power of Attorney (POA), the Department concluded the above allegation SUBSTANTIATED. This deficiency was cited on complaint control # 27-AS-20251107134505, dated 11/07/25, therefore the Department will not be reissuing this citation as it is within the same investigation window. Substantiated Allegation: Licensee did not ensure that the resident’s room was kept clean and sanitary. LPA reviewed photographs of R1's room that were taken on Friday, 12/05/25. LPA observed a photo (#1) of a document showing that R1's room was scheduled to be cleaned twice a week on Wednesdays and Saturdays. Another photo (#2) was of a full laundry basket in R1's closet. In a third photo (#3), this LPA observed a rolled up adult brief on the floor, a terry cloth towel in a bedside trash can, and what appeared to be feces on the carpet and several brown stains in the carpet by the side of the bed. There were also crumpled tissues and other scraps of paper and trash on the floor. Another photo (#4) was taken in the bathroom and was of the toilet bowl which was stained on the rim with smeared feces and urine. In another photo (#5), it can be observed that there was blue tape along the entire corner and side (roughly 8-10 inches) of the countertop securing it in place. A separate case management will be conducted to address the fixture being in disrepair. The Department has concluded, based on the preponderance of the evidence obtained during this investigation, that the above deficiency was SUBSTANTIATED. This deficiency has been cited on the LIC 9099D page. Allegation: Licensee did not ensure that the responsible party was provided resident's medical records in a timely manner. The POA for R1 requested R1's medical information in writing on 10/27/25. The facility did not provide the documents until 11/04/25, 8 days later. This was a violation of Health & Safety Code 1569.269(a)(21) which states that residents, or their valid power of attorney, have a right to prompt access to records; copies provided within 2 business days. The Department has concluded, based on the preponderance of the evidence obtained during this investigation, that the above is SUBSTANTIATED. This deficiency has been cited on the LIC 9099D page. LPA conducted a tour of the facility prior to this exit interview and observed residents in the dining areas preparing for lunch and an outside agency facilitating fellowship. According to the California Code of Regulations, Title 22, no other deficiencies were observed or cited during today's visit, a copy of this report was provided along with APPEAL RIGHTS. An exit interview was conducted with Administrator Reyes, and a case management visit will also take place today to address any deficiencies observed during the course of this investigation. staff will assist them with anything they may need. R6 also stated that staff really go out of their way to assist the other residents. Based on interviews the above allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation was unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Allegation: Licensee did not ensure that a fall prevention plan was implemented to ensure resident's safety while in care. A review of R1's file was conducted. On 09/15/24 it was noted on R1’s care Plan that R1 was a risk for falls. The facility implemented that staff will encourage R1 to stay in common areas, encourage participation in activities, ensure R1 is wearing appropriate fitting clothes and shoes. On 07/22/25, R1 sustained a fall. The following fall plan was implemented: Staff will evaluate R1 before moving to check for range of motion, conduct frequent checks, monitor for three days after a fall occurs, report any changes in condition. Staff will evaluate location of fall to identify any factors which could have contributed to the fall. Staff will encourage R1 to attend activities and promote exercise. Based on a review of records, it was determined that the facility did put a fall plan in place for R1 and the above allegation wad unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Allegation: Licensee did not ensure that there was enough staff to meet the needs of the residents. Based on interviews with 4 residents, observations made by LPA and IB investigators at times of visits on: 08/07/25, 11/07/25, 11/13/25, 11/14/25, 11/24/25, 11/25/25, 12/16/25, the above allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Allegation: Facility failed to meet residents needs which resulted in death. On 03/03/26 records were reviewed from Sutter Hospital. On 09/01/25, R1 was sent to hospital due to a fall. X-rays were taken and no sign of injury was identified, so R1 was sent back to the facility. On 09/20/25, R1 complained of pain and was sent back to the hospital. This time a CT was conducted that showed signs of a closed fracture. Based on the records reviewed, the facility obtained medical attention each time R1 exhibited pain and cared for the resident based on the hospital tests conducted. The above allegation was unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Allegation: Licensee did not ensure that staff did not administer unauthorized medication to resident while in care. According to the Power of Attorney for Medical (POA) for R1 on 09/03/24, they contacted R1's primary care physician's office. The POA told the physician assistant (PA) to immediately take R1 off of Seroquel. According to The POA, the PA agreed except for a PM dose at 8:00PM, if needed. LPA reviewed the orders faxed over by the physician's office on 09/08/24 which stated, "Take quetiapine (the generic for the above mentioned medication) 25mg twice daily (in the morning 8AM and in the evening 8PM)". LPA reviewed the Electronic Medication Record (EMAR) for R1 for that time period and it showed that the facility followed the written orders provided by the doctor's office, as they are required to do according to the California Code of Regulations, Title 22. Based on this review of records, the above allegation was unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. LPA conducted a tour of the facility prior to this exit interview and observed residents in the dining areas preparing for lunch and an outside agency facilitating fellowship. According to the California Code of Regulations, Title 22, no other deficiencies were observed or cited during this visit. A copy of this report was provided, along with APPEAL RIGHTS and an exit interview was conducted with Administrator Reyes.the state’s words, verbatim · CDSS document, Jul 15, 2026 · control 27-AS-20251113084659

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Jul 31, 2026

Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities... (2) To be accorded safe, healthful and comfortable accommodation, furnishings and equipment. The above requirement was not met when: Based on a review of the 5 photos received by this LPA, it was observed that the carpet had brown stains and that there was feces and an adult brief on the floor along with crumbled tissues and trash. The posed a potential risk to the health, safety, and personal rights of residents in care.the state’s words, verbatim · CDSS document, Jul 15, 2026

Plan of correction: Administrator will have the Resident Care Coordinator Pam Chore track the room inspections she does and turn it to licensing by 07/31/26 to CCLASCPSacramentoSoutRO@dss.ca.gov

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.269(21) · Plan of correction due date: Jul 31, 2026

1569.269 (21) Enumerated rights; severability -To have prompt access... their records... Photocopied records shall be promptly provided, not to exceed two business days... The above requirement was not met when: Based on interviews with the POA, the advocate and S1, the records were requested in writing twice and were not delivered until 11/04/25. This posed a potential threat to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Jul 15, 2026

Plan of correction: Administrator stated that they will conduct a training with staff on document requests made responsible parties/families/POAs and Conservators. * This page was amended to include the information on the left. Nothing else was added or deleted.

Type of visit: Case Management - Deficiencies

On 07/15/26, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to conduct a case management visit as a follow-up to delivering the findings for complaint #27-AS-20251113084659 on 07/15/26. LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator. LPA met with Administrator Janessa Reyes and a brief meeting followed. LPA reviewed photographs of R1's room showing that the bathroom vanity countertop was being held together with an 8-10 inch strip of tape. LPA viewed the room today during a walkthrough and it has since bee repaired. This deficiency has been cited on the LIC 809D page and has also been cleared. During the course of this investigation, this LPA reviewed shower logs. LPA reviewed a total of 53 shower logs from October through December of 2025. Out of the 53, 17 were incomplete. 8 did not have skin assessments completed, 5 were not signed by care staff, 6 did not have residents names or room numbers for identification purposes, and 3 did not have the required medication technician signature present if a resident refused a shower. This deficiency was cited on the LIC 809D page. According to the California Code of Regulations, Title 22, no other deficiencies were observed during today's visit, a copy of this report was provided along with APPEAL RIGHTS and an interview was conducted with Administrator Reyes.the state’s words, verbatim · CDSS document, Jul 15, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jul 15, 2026

(a) The facility shall be clean, safe, sanitary and in good repair at all times. The above requirement was not met when: Based on a review of photos, the above requirement was not met when the facility used tape to secure the countertop in the bathroom of R1's room. This posed a potential threat to the health, safety and/or personal rights of residents in care.the state’s words, verbatim · CDSS document, Jul 15, 2026

Plan of correction: The Administrator stated that all repairs were made to the room prior to a new resident moving in. LPA verified this by touring the room. This PC has been cleared.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87411(a) · Plan of correction due date: Jul 31, 2026

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. The above requirement was not met as evidenced by: Based on record review of 17 out of 53 shower logs, the above requirement was not met when staff did not complete shower logs for the residents in their care. This posed a potential threat to the health, safety, and personal rights or residents in care.the state’s words, verbatim · CDSS document, Jul 15, 2026

Plan of correction: Administrator stated that since they have assumed the position, she conducts an audit of shower logs every day. Administrator will send examples of thoroughly completed shower sheets that will be used for training purposes.

Type of visit: Case Management - Deficiencies

On 07/15/26, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to conduct a case management visit as a follow-up to delivering the findings for complaint #27-AS-20251107134505 on 07/13/26. LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator. LPA met with Administrator Janessa Reyes and a brief meeting followed. In the above complaint this LPA learned when the resident (R1) was admitted, their care plan stated that they were able to take care of their own ostomy appliance. Over time it was observed by staff that the dexterity in R1's hands was not enough to perform the tasks associated with utilizing their ostomy appliance on their own and accidents were happening that created an unsanitary environment. These observations should have been documented and should have triggered a reappraisal. A new care plan should also have been developed to meet the resident's needs. These deficiencies have been cited on the LIC 809D page. According to the California Code of Regulations, Title 22, no other deficiencies were observed during today's visit, a copy of this report was provided along with APPEAL RIGHTS and an interview was conducted with Administrator Reyes.the state’s words, verbatim · CDSS document, Jul 15, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Aug 11, 2026

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes...and that appropriate assistance is provided... The above requirement was not met when: Based on interviews with the ED, the AIT, and Housekeeping staff, R1's room was cleaned 2X daily due to them dropping things including their ostomy pouch demonstrating that they could not care for the medical appliance independently. This posed a potential threat to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Jul 15, 2026

Plan of correction: Administrator stated they will conduct an inservice on documentiong observations ad reporting them to the appropriate supervisor in a timely manner. Signature sheets with the agenda will be sent to licensing at CCLASCPSacramentoSouthRO@dss.ca.govby 08/11/26.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87463(b) · Plan of correction due date: Jul 31, 2026

Reappraisal (b) The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition... The above requirement was not met when: Based on record review R1 never received an updated appraisal even though it was observed that they could not care for their ostomy pouch. This posed a potential threat to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Jul 15, 2026

Plan of correction: Administrator stated that they will draft an attestation regarding reappraisals and when to condcut them, emphasizing the importantance of communication. The three Managers responsible for care will sign off and submit to Licensing by 07/31/26 at CCLASCPSacramentoSouthRO@dss.ca.gov.

Allegation investigated: Staff do not answer resident's call button in a timely manner. Staff do not dispense medications as prescribed. Staff do not treat resident with dignity. Staff do not ensure that colostomy bags are properly discarded.

On 07/13/26 Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver the findings of this complaint investigation. LPA identified herself upon arrival, stated the purpose of the visit and asked to meet wiht the Designated Facility Administrator. LPA met with Janessa Reyes and a brief meeting followed. Allegation: Staff do not answer resident's call button in a timely manner. On 12/18/25 LPA Michael Bilger spoke to S4 who stated that they have witnessed staff providing care for a resident, has no concerns with their own care or other residents' care, and stated that staff are providing “the best care they can.” LPA also observed that there was 1 med tech, 2 care givers, 1 resident care Director and 1 Wellness Care nurse available to provide care to 20 residents. Residents were well looked after and none appeared, worried, sad, or in pain. Based on interviews and observations the above allegation is unsubstantiated. Unsubstantiated Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Allegation: Staff do not dispense medications as prescribed On 12/18/25, LPA Bilger conducted a review of medication log sheets and determined that medications were logged correctly and given as prescribed. Based on record review the above allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Allegation: Staff do not treat resident with dignity. On 07/13/26, LPA interviewed the responsible parties for 3 residents who were living on the same hallway as R1, 1 resident living on that hallway at the time of this complaint, and 3 staff who were working at the time of this complaint. 6 out of 7 individuals interviewed stated that the staff treated all residents with dignity. One stated that they had not seen any evidence of a resident not being treated with dignity. Based on interviews, the above allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Allegation: Staff do not ensure that colostomy bags are properly discarded. On 07/13/26, LPA interviewed the responsible parties for 3 residents who were living on the same hallway as R1, 1 resident living on that hallway at the time of this complaint (R4), and 4 staff who were working at the time of this complaint (S4-S7). LPA learned that R1's room was cleaned every day at approximately 9:00 AM by S4 when R1 would go to breakfast and then once again in the afternoon. S4 would take the trash out during both of those visits. Care givers would also remove trash upon request. It was noted by all staff and the resident interviewed, R4, that when R1 requested assistance, they expected immediate assistance and sometimes that was not possible as they were assisting other residents. R4 stated that they talked to R1 on more than one occasion about their demands, reminding R1 that staff had other residents to assist. Out of the 7 interviews conducted, 1 responsible party (RP1) stated that they had seen bags of trash (which contained a colostomy bag) in R1's room. This LPA asked if they had used the call button to request that The following deficiency, 87464(F)(2) was cited per California Code of Regulations, TITLE 22, DIVISION 6, CHAPTER 8 Article 8. According to the California Code of Regulations Title 22, no other deficiencies were cited during today's visit, a copy of this report was provided and an exit interview was conducted with Reyes. that staff dispose of the trash, and if so, how long did it take before they arrived? RP1 replied that they did not, they "took care of it." Based on interviews, the above allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. This LPA did observe during her visit with R1 on 11/26/25, that the trash receptacle in R1's bathroom did not have a lid as required for solid wastes, This deficiency will be cited per the California Code of Regulations, Title 22, 87303(f)(3) during a future case management visit. During that case management visit, this LPA will also address the fact that a reappraisal should have been conducted when staff first realized that R1 did not have the dexterity in their hands to care for their own ostomy bag resulting in the bag being dropped on the floor or placed in the trash still open and not knotted closed. According to the California Code of Regulations Title 22, no other deficiencies were cited during today's visit, a copy of this report was provided and an exit interview was conducted with Reyes.the state’s words, verbatim · CDSS document, Jul 13, 2026 · control 27-AS-20251107134505

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(F)(2) · Plan of correction due date: Jul 20, 2026

(f) Basic services shall at a minimum include: (2) Safe and healthful living accommodations and services, as specified in Section 87307, Personal Accommodations and Services. The above requirement was not met as evidenced by: Based on interview with RP, resident advocate, R1 and POA of R2, the above allegation is substantiated. This posed a potential threat to the health safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Jul 13, 2026

Plan of correction: Administrator stated that they will submit an audit of all the individuals who require daily cleaning/laundry services due to high incontinent care needs to Licensing at CCLASCPSacramentoSouthRO@dss.ca.govby the close of business on 07/31/26.

Allegation investigated: Licensee not ensuring that residents' care needs are being met

On 1-16-2026 at 2:30pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver findings for the allegation noted above. LPA met with wellness nurse Joanne Blackburn and explained the purpose of the visit. Administrator made aware by facility staff of LPA's visit and purpose. During this investigation, LPA conducted interviews with four staff members and one resident in care. LPA also reviewed facility file documentation including service plans, medication log sheets, physician’s orders, physician’s report, hospice documentation, and progress notes pertaining to resident1 (R1). Additionally, LPA conducted a facility observation on 12-18-2025. Allegation: Licensee not ensuring that residents’ care needs are met. LPA conducted interviews and record reviews as noted above. This allegation references R1 and the presence of blisters and rashes throughout R1’s body as well as a presence of pain. Based on these interviews and record reviews it was revealed that R1 experienced blisters and rashes on various parts of R1’s body within the review period of October 2025 to December 2025. It was further revealed that R1 began receiving hospice services on or about 11-17-2025 which included continued treatment of blisters and rashes as well as pain management. {Cont.on 9099C} Unsubstantiated A review of hospice documentation revealed consistent follow up of R1’s condition and updates to physician orders as well as communication with facility staff. Facility progress notes further revealed on-going follow up of R1’s blisters and rashes and other conditions as well as acknowledgement of all physician orders. A review of medication log sheets indicates R1 was assisted with prescribed medications consistently which included topical creams and oral medications to address skin conditions and pain. Interviews conducted did not reveal any corroborated evidence of staff not ensuring care needs for residents in care. An observation by LPA conducted on 12-18-2025 revealed staff attending to various resident needs in a timely and appropriate manner. As a result, although R1 has experienced skin and other conditions during R1’s stay at facility, there is not a preponderance of evidence to conclude staff is not ensuring care needs are met, therefore the above allegation is UNSUBSTANTIATED. A finding of unsubstantiated means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with wellness nurse and a copy of this report was provided. LIC 811 and Appeal rights provided.the state’s words, verbatim · CDSS document, Jan 16, 2026 · control 27-AS-20251216161036

Allegation investigated: Facility violated a resident's personal rights by sending their medical information to an unauthorized person.

On 11/26/25, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to open a complaint investigation into the above allegation. LPA identified herself upon arrival, stated the purpose of the visit, and asked to meet with Designated Facility Administrator/Executive Director (ED). LPA met with Designee / Wellness Nurse, Joanne Blackburn and a brief interview followed. LPA explained that it was reported to Community Care Licensing that when a responsible party for a resident, (R1) requested a copy of R1's medical file, another resident's (R2) confidential medical information was included within in it. LPA received a copy of that medical documentation for R2. LPA requested to review the medical files for R1 and R2 during today's visit. LPA and the Designee found that R2's medical information from 2023 was misfiled in R1's file. Based on interviews and a record review, the licensee did not ensure the confidentiality of record contents and made available confidential information which posed an immediate risk to the health and safety or Substantiated rights to persons in care. This deficiency has been cited on the LIC 9099 D page. Due to time constraints, this LPA will conduct a walkthrough of the facility during the opening of a complaint investigation which will take place immediately following this visit. According to the California Code of Regulations, Title 22, no other deficiencies were observed or cited during this visit. A copy of this report was provided along with APPEAL RIGHTS and an exit interview was conducted with Designee Blackburn.the state’s words, verbatim · CDSS document, Nov 26, 2025 · control 27-AS-20251125172322

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87506(c)(1) · Plan of correction due date: Nov 27, 2025

(c) All information and records...residents shall be confidential. (1)The licensee shall be responsible ...confidentiality of their contents. The licensee...only upon the resident's written consent or that of his designated representative. The Licensee did not meet the above requirement as evidenced by: Based on interviews and record review, the licensee did not ensure the confidentiality of record contents and made available confidential information which poses an immediate Health Safety or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 26, 2025

Plan of correction: Designee stated that over the next 24 hours they will conduct a training regarding the importance of maintaining resident confidentiality and appropriately filing all documentation. Signature sheets for those who attend the training will be submitted to Licensing at: CCLASCPSacramentoSouthRO@dss.ca.gov with a copy to kimberly.viarella@dss.ca.gov. Designee will also submit an audit of all resident files to ensure that they do not contain any misfiled information. All of the above will be submitted by 11/27/25.

Type of visit: Case Management - Incident

On 11/24/25, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to conduct a case management visit regarding deficiencies observed during the last visit when this LPA opened a complaint investigation (complaint # 27-AS-20251113084659) on 11/14/25. LPA identified herself upon arrival, stated the purpose of the visit, and asked to meet with Designated Facility Administrator/Executive Director (ED). LPA met with Toni Jones and a brief meeting followed. On 11/14/25, this LPA observed that there were 2 staff member, (S1 and S2) who were not associated to the facility as required by the California Code of Regulations, Title 22. Due to time constraints, this LPA was unable to conduct the case management that day, but is citing for this deficiency today on the LIC 9099 D. An immediate civil penalty for $1,000.00 for caregiver background clearance was also assessed today. This LPA to open a complaint investigation following this visit and observations from a facility walkthrough will be documented at that time. According to the California Code of Regulations, Title 22, no other deficiencies were cited during this visit, a copy of this report was provided and an exit interview was conducted with Toni Jones.the state’s words, verbatim · CDSS document, Nov 24, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(3) · Plan of correction due date: Nov 24, 2025

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above when 2 staff (S1 and S2) did not have their background clearances completed and were not associated to the facility. This posed/poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 24, 2025

Plan of correction: The Executive Director told S1 and S2 they could not work until they had their clearances and the ED sent them out to be fingerprinted. Both were cleared and associated on 11/14 and 11/16 respectively. This POC had been cleared.

Type of visit: Case Management - Annual Continuation

On 8/11/2025, Licensing Program Analysts (LPA) Arvin Villanueva arrived at this facility unannounced to conduct a case management-continuation visit to continue the annual inspection initiated on 8/7/2025. LPA met with Administrator Toni Jones and stated the purpose of the visit. Initial Observation: Upon arrival, LPA observed some residents participating in a morning exercise led by staff on duty. LPA observed the room temperature at 75 degrees Fahrenheit. Today's visit, LPA conducted 5 staff record reviews. Advisory was provided to ensure staff providing resident care have at least their first aid training updated. LPA reviewed 2 residents' medication. Medications were observed locked and inaccessible to residents in care. LPA conducted review of facility's Infection Control Plan and Emergency Disaster Plan. Advisory was provided to Administrator to review their plans at least annually or as needed and ensure to document every review. Per review, facility conducts drills at least quarterly. Last drill was 7/3/2025. Last Fire Marshal inspection was conducted on 8/5/2025. According to the California Code of Regulations, Title 22, no deficiencies were observed or cited during today's visit. Exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 11, 2025

The state marks this report as 5 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

On 8/7/2025, Licensing Program Analyst, Arvin Villanueva (LPA) arrived unannounced at this facility to conduct their annual inspection visit. LPA met with Administrator Toni Jones and stated the purpose of the visit. Overview: Facility is licensed to serve up to 85 elderly adults. Each room was cleared to accommodate non-ambulatory residents. Facility can admit/retain up to 15 residents receiving hospice services. Facility consists of 2 Memory Care houses and 2 Assisted Living houses. Initial Observation: LPA met with Toni at one of the houses. Residents were observed to be in the activity area waiting for activity to start. There was a live music concert during this visit. Physical Inspection: Areas inspected include, but not limited to, resident bedrooms, resident bathrooms, living and dining room and outdoor areas. LPA observed the inside of the facility to be clean and in good repair at this time. LPA and Administrator inspected 5 resident bedrooms and were observed to be equipped with the required furniture and sufficient lighting throughout. LPA measured the hot water temperature in the 2 resident bathrooms to be at 107 degrees Fahrenheit. The 2 resident bathrooms were observed to be in clean and good repair at this time. Fire extinguishers were observed in the each of the 4 houses and were last inspected on 1/7/2025. Smoke and carbon monoxide detectors were observed throughout each houses. Per Administrator, food for the residents in the Memory Care and Assisted Living are prepared in the Skilled Nursing kitchen, which is a separate building but within the same compound. {Con't to 809-C} {Con't from 809} Outdoor area was inspected. LPA observed outdoor furniture for resident use. Ramps were observed to be in good repair at this time. Emergency walkways were observed to be unobstructed. No bodies of water was observed. Record Reviews: Review of 5 of 5 resident files (R1 - R5) was conducted, include review of Admission Agreement, Physician Reports, Needs and Services Plan, and Ambulatory Status. Based on today's visit, this annual will need a continuation visit. The Department will return at a later date to continue the annual inspection. Exit interview was conducted. A copy of the report was provided upon exit.the state’s words, verbatim · CDSS document, Aug 7, 2025

Allegation investigated: Staff did not ensure that resident was treated for a scabies infection.

On 12/17/24 Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to continue a complaint investigation into the above allegation. LPA identified herself upon arrival, stated the purpose of the visit, and asked to meet with Designated Facility Administrator. LPA met with Designee, Toni Jones and a brief interview followed. LPA conducted a document review and learned the following. R1 was sent to the hospital for a fall. While at the hospital, R1 was assessed by a dermatologist who determined that the rash R1 had on the lower half of R1's body was consistent with scabies. A topical medication was administered before R1 was discharged with additional medication to be administered by the facility. LPA reviewed R1's care plan. On page 6 of the care plan for R1, it stated that R1 "had bladder incontinence. Resident refuses to wear underwear or adult briefs. Staff to toilet resident every 2 hours." This part of the plan was updated 09/07/24. Substantiated LPA requested shower logs/sheets for 2 months. LPA was told that shower sheets were only kept for 1 month. LPA informed staff that the shower sheets were part of the residents' care and thus a part of their permanent file. The information does not need to be kept in their regular file, but should be stored and accessible if requested. 11/27/24 Shower sheet for R1 was completed by staff (S6) who wrote "yes" for observing a rash and a bruise but did not indicate where. 12/02/24 Shower sheet was completed by staff (S5) who checked "yes" for bruise and reddened area and put an "X" next to rash. There was also a note that the resident refused a shower. 12/04/24 Shower sheet was completed by staff (S6) who checked off that there was a bruise and a rash and that the skin was intact. 12/11/24 Shower sheet was completed by staff (S7) who wrote "Yes" for rash and reddened area and highlighted 4 areas on R1's upper and lower legs. On 12/12/24, LPA interviewed R1 and R1 stated their legs were itchy. LPA suggested the nurse assess R1's legs. The nurse later reported to the LPA that R1's legs were covered in a rash and R1 was being sent out for further evaluation. From 11/27/24 - 12/12/24, R1 received 3 showers. During an interview with S3, this LPA learned that it was not standard practice to have the shower sheets reviewed and signed off by a Medication Technician, Care Coordinator, or Nurse to ensure that they were being completed thoroughly and that all showers and skin checks were being conducted as scheduled. LPA reviewed hospital discharge notes dated 11/27/24. On page 1 it stated, "Found to have scabies; treated with..." Based on the document review and the information gathered from interviews with S3 and S1, the standard for the preponderance of evidence has been met and the department found the allegation, "Staff did not ensure that resident was treated for a scabies infection," SUBSTANTIATED. According to the California Code of Regulations, Title 22, this deficiency is cited on the LIC 9099D page. No other deficiencies were observed or cited during todays' visit. A copy of this report was provided along with APPEAL Rights and an exit interview was conducted.the state’s words, verbatim · CDSS document, Dec 17, 2024 · control 27-AS-20241204153321

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Jan 10, 2025

Observation of the Resident: The licensee shall ensure...residents are regularly observed for changes... and that appropriate assistance is provided... physical health...are observed, the licensee shall ensure...are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. The above regulation was not met as evidenced by: Based on a review of hospital discharge paperwork and shower logs along with interviews with S3 and S1, R1 had a change of condition (the rash) and should have been sent to the hospital for evaluation. This posed an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 17, 2024

Plan of correction: Care Coordinators to document into Point and Click into "Health Notes" regarding the status of showers. Nurse to conduct in-service reviewing skin check procedures and the protocol for communicating that a resident has had a change of condition. The facility will submit signature sheets for the training (along with the name of the person/organization to conduct training). It will also send a screenshot of the PCC system to demonstrate this new process. All due to CCL by 1/10/25.

Type of visit: Case Management - Other

On 12/17/24, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced case management visit to this facility. The purpose of this visit was to follow up with this quarterly visit and inquire about the requirements that were laid out in an office meeting which took place on 3/19/24 . The LPA identified herself upon arrival, stated the purpose of the visit, and asked to meet with the Designated Facility Administrator. LPA met with Toni Jones and a brief interview followed. In summary the facility agreed to the following and will provide the department documentation of policy and procedure changes. Updated one on one supervision policy Documentation of most recent reporting requirements training and mandated reporter training to be completed every six months. Increased oversight of the facility by licensee as regional director will be on site once per month to ensure compliance. Facility completed TSP. LPA requested copies of the following: Updated one-on-one supervision policy Documentation of the most recent reporting requirement training and mandated reporter training Log of site visits by the regional director LPA received the documents requested. LPA and Designated Facility Administrator conducted a tour of the facility. In memory care, LPA observed 6 staff in memory care: 4 caregivers and 2 medtechs. LPA observed a medication cart during the tour and checked to ensure that all medications were locked and inaccessible to residents in care. Memory care was free of odor and LPA observed 16 residents in the dining room preparing for lunch. In assisted living, LPA observed 10 residents listening to an entertainer singing. 3 other residents were sitting by the fireplace and all were being supervised by 2 carestaff. According the California Code of Regulations, Title 22, there were no deficiencies observed or cited during this visit. A copy of this report was provided. Exit interview.the state’s words, verbatim · CDSS document, Dec 17, 2024

Allegation investigated: Staff neglect resulted in resident sustaining serious bodily injury Staff neglect resulted in resident sustaining an unwitnessed fall

Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to deliver complaint findings. LPA Valerio met with Administrator , and explained the purpose of the visit. On 09/05/2024, The Regional Office conducted an unannounced visit and learned Resident 1 (R1) was not a resident of the facility. On 09/05/2024, LPA Moleski could not acquire documentation regarding a resident (R1) as they are a resident of a skilled nursing facility, which is outside the jurisdiction of the Community Care Licensing Division. On 09/06/2024, complaint information was cross reported to the Department of Public Health. Based on the above noted information, the allegations are deemed Unfounded. The allegation is UNFOUNDED, meaning that the allegation was false, could not have happened and/or was without a reasonable basis. This Department has therefore dismissed the complaint. Per California Code of Regulations (CCR) - Title 22, no deficiencies were observed or cited. An exit interview was held, and a copy of the report was provided. Unfoundedthe state’s words, verbatim · CDSS document, Sep 16, 2024 · control 27-AS-20240904110359

Type of visit: Case Management - Incident

On 8/29/24 at 2:00pm Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced Case Management inspection at Gramercy Court to address and incident report from 4/1/23 where it was disclosed a resident had sexually harassed another resident in the facility. LPA met with administrator Veronica Morales and together discussed the reported incident and obtained additional information. LPA Gould conducted an interview with one resident. Based on the interviews and information gathered during today's inspection, the department will conduct additional interviews and file review before making a determination regarding the reported incident. Exit interview was conducted and a copy of this report was left a the facility.the state’s words, verbatim · CDSS document, Aug 29, 2024

Type of visit: Case Management - Incident

This is an amended report to correct a typo observed after LPA Gould final printed report. On 8/28/24 at 9:00am Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced Case Management inspection at Gramercy Court to address and incident report from 4/1/23 where it was disclosed a resident had sexually harassed another resident in the facility. LPA met with administrator Veronica Morales and together discussed the reported incident and obtained additional information. LPA Gould reviewed three resident files and requested copies of resident appraisals, physician reports, ID and emergency information, admission agreement, any incident reports/SOC 341 and any progress notes for the identified residents on our about April 2023. LPA Gould conducted interviews with two staff member and one resident. LPA attempted to interview another resident but was enjoying a preferred activity and did not with to converse with LPA at the time of inspection. Based on the interviews and information gathered during today's inspection, the department will conduct additional interviews and file review before making a determination regarding the reported incident. Exit interview was conducted and a copy of this report was left a the facility.the state’s words, verbatim · CDSS document, Aug 28, 2024

Type of visit: Required - 1 Year

An unannounced Annual Inspection visit was made by Licensing Program Analyst (LPA) Kimberly Viarella to this facility on 08/09/24. LPA identified herself, explained the purpose of the visit, and asked to speak with Designated Facility Administrator (DFA). LPA met with Veronica Morales, the Residential Care For the Elderly (RCFE) Administrator. LPA observed that the Designated Facility Administrator's certificate, # 6002544735 expired on 05/05/26. LPA began by comparing the LIC 500 staff roster with the Guardian roster to ensure that all staff were appropriately cleared and that their background checks had been completed. All staff were in compliance at the time of inspection. LPA conducted a walkthrough of the facility. LPA inspected 3 resident rooms. All had the required furniture, furnishings and lighting to be in compliance at this time. LPA also observed 5 residents playing cards memory care. LPA noted soap, grab bars and non-skid surfaces in the showers. LPA measured the hot water and it was 107.3 degrees Fahrenheit and in compliance. LPA observed the fire extinguishers were last serviced on 01/03/24 Sentinel Fire Co. were also in compliance. The exterior of the facility was inspected by the LPA. There were no bodies of water present and the yard was completely fenced in. LPA observed that all screens and gutters were in good repair. There was 1 storage shed with a lock that contained yard equipment and storage items. There was also a covered patio area for residents to enjoy. LPA observed facility van taking 6 residents to Walmart. The LPA observed medication carts in the dining rooms of assisted living and memory care. LPA checked to ensure they were locked and medications were inaccessible to residents in care. LPA reviewed storage, dosing, and destruction procedures. A review of the First Aid kit by the LPA found it to be complete and in compliance. LPA was informed that each medication cart had first aid items and each medication room had full first aid kits at the time of inspection. A file review was completed by the LPA. 2 of 3 of the resident files reviewed were missing current LIC 602s (Physicians Reports) and updated care plans. Due to time constraints, this LPA reviewed 2 staff files and found them to be in compliance at the present time. LPA interviewed 3 residents who stated they were happy at Gramercy Court, liked the food, and enjoyed the activities provided. According to the California Code of Regulations, Title 22, the following deficiencies were observed and cited on the LIC 809 D page. A copy of this report was provided along with APPEAL rights and an exit interview was conducted with the Designated Facility Administrator.the state’s words, verbatim · CDSS document, Aug 9, 2024

Type of visit: Case Management - Other

On 08/02/24 Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to conduct a quarterly case management visit. This visit was a follow up to a meeting conducted virtually with Community Care Licensing on 03/11/24. LPA identified herself upon arrival, stated the purpose of the visit, and asked to meet with the Designated Facility Administrator (DFA). LPA met with Veronica Morales and a brief interview followed. LPA reviewed the mandated reporting log from 2/23/24. The next training is tentatively scheduled for this August 2024. The DFA stated she was waiting to hear back from multiple agencies to confirm an exact date. Once the date is confirmed, Licensing will be notified. LPA and DFA discussed how the mandated reporting and reporting requirement training was implemented. The DFA stated she utilized videos, handouts and staff were also tested on the materials. LPA was provided a copy of the mandated reporting pre-test and handouts. Upon reviewing the materials, LPA noted that they needed to be updated to reflect the change in the law that occurred in January of 2024 which required incidents of abuse to be reported verbally within 2 hours to law enforcement, the local ombudsman, and licensing, and an SOC 341 should be submitted within 24 hours. The Licensee agreed to have additional oversight of the facility by having the Regional Director, Dan Bushnell, conduct on site reviews of operations monthly. When the LPA asked the DFA for the dates of these monthly inspections, she could not provide one. The DFA stated that the Regional Director makes unscheduled visits 2-3 times a month but she did not have those visits documented. The DFA added that the Regional Director schedules virtual meetings during the month to discuss concerns. The DFA also stated that she sends weekly reports on Fridays that include the current census, number of hospice, move outs/in, pending admissions, any incident reports, SOC 341s, or other concerns. LPA went on to review the 1-1 caregiver supervision policy created by the Skilled Nursing Administrator and the DFA. A copy of this document was emailed to Community Care Licensing. LPA and DFA discussed eviction procedures. DFA had previously contacted this LPA seeking guidance regarding evictions. LPA has reviewed all eviction notices to ensure compliance. As part of this visit, LPA and DFA conducted a walkthrough of the facility. LPA observed 10 residents in one of the two dining rooms of memory care along with 3 care staff and 1 med tech. The Olympics were on TV in the background. LPA walked through the assisted living building as well. LPA observed 5 residents in the dining area of assisted living. LPA did not observe any activities during this visit but was told that all residents were offered the opportunity to participate in a daily exercise class and the Activity Director conducted Bingo in memory care. In assisted living there was a movie accompanied by popcorn following their exercise class. According to the California Code of Regulations, Title 22, no deficiencies were observed or cited during today's visit. A copy of this report was provided. Exit interview.the state’s words, verbatim · CDSS document, Aug 2, 2024

Allegation investigated: Staff gave wrong medications to resident in care

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to the facility to conduct a complaint investigation visit and deliver complaint investigation findings. LPA Valerio met with Skilled Nursing Administrator Nima Pourfathi and Memory Care and Assisted Living Administrator Veronica Morles, and explained the purpose of the visit. During today's visit, LPA Valerio interviewed staff, reviewed facility records, and observed the facility. The facility was observed to be clean, free from debris, and free from obstructions of emergency exits. No immediate health or safety concerns were observed. The Department has determined the following as it relates to the following allegation: Staff gave wrong medications to resident in care Continues on LIC 9099 - C... Substantiated Continues from LIC 9099 Based on records review and information from the Reporting Party (RP), the facility administered medications for Resident 1 (R1) to Resident 2 (R2). Facility Staff, Staff 1 (S1), realized the error after checking the computer system. According to S1, S1 notified the Wellness Nurse Supervisor immediately after the error. It was confirmed by interviews with Designated Administrator, Wellness Nurse, and Staff 1 that R2 was provided the wrong medications. Per California Code of Regulations (CCR) - Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached LIC 9099 - D page. Continued from LIC 9099 The RP learned of the medication error after receiving an Unusual Incident Report (UIR) on 02/13/2024 from the facility. The UIR stated that the medication error occurred on 12/18/2023. According to the UIR, the staff contacted the "LN" (Lead Nurse), which then contacted emergency medical services (EMS). R2 was transported via Alpha One to the Emergency Room and came back the next day with no orders or discharge information. According to the RP, the incident occurred at or around 9:34 AM and the family was not spoken to until 11:42 AM. According to a review of the facility records, a note was written on 12/18/2023 at 09:36 AM. Note stated the following: "Resident was given the wrong medications by error. Residents' son and PCP notified. Alpha one called and resident sent to Kaiser ER for evaluation". According to an interview with Administrator Veronica, the facility usually writes the time of when people are contacted; however, during this incident, the times were not written. According to interviews with facility staff, all staff deny delaying a call to EMS. Based on interviews with staff, all staff state that EMS was contacted immediately after the incident. Staff also stated that they spoke to staff during the incident and after the incident had occurred According to a review of the facility records, a note was written on 12/19/2023 14:27 (2:27PM). Note stated, "Resident came back from the hospital around 1:52 P.M. with the daughter. Per RCC, there are no changes of medication and no discharge paper as well. Wellness Nurse and Administrator and Other RCC was informed, also faxed PCP." Based on all the information collected by the Department there is not a preponderance of evidence to prove the allegation occurred, therefore this allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, and therefore the allegations are unsubstantiated. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited regarding the above-mentioned allegation. An exit interview was held and a copy of report was left at the facility.the state’s words, verbatim · CDSS document, May 6, 2024 · control 27-AS-20240405131806

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(5) · Plan of correction due date: May 7, 2024

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility...:(5) Facility staff, ...designated by the licensee may assist persons with self-administration as needed....This requirement was not met as evidence by: Based on records review and interviews, the licensee admitted that R2 was given R1's medication, which poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 6, 2024

Plan of correction: Licensee stated they provided an in-service to the staff on the topic: The Six Rights of Medication Administrator. Licensee to submit a copy to LPA by POC due date.

Type of visit: Case Management - Legal/Non-compliance

On 3/19/24 at 10:00am, Department representatives Kevin Gould (LPA), Kim Viarella (LPA), Czarrina Camilon-Lee (LPM), Stephen Richardson (LPM) and Stephenie Doub (RM) met with representatives from Gramercy Court to discuss recent compliance issues at the facility and the steps the facility is taking to address the department's concerns. Representing Gramercy Court is Dan Bushnell - Regional Director, Veronica Morales - Administrator, Nima Pourfathi - Administrator (Gramercy skilled nursing). Department and facility representatives recent concerns of non-compliance including reporting requirements. The department discussed concerns with reporting incidents that pose a danger to residents in a timely manner consistent with title 22 regulations. The facility has conducted reporting training and training on mandated reporting. The facility agreed to conduct training on mandated reporting and reporting requirements every six months. Department and facility representatives discussed re-evaluation and the facility following their own plan of operations and admission agreements regarding evictions when a resident may pose a danger to themselves or others. Facility representatives discussed steps taken including a new management team at Gramercy Court and the inclusion of facility nurse to assist in the evaluation and appraisal of residents prior to admission and regularly when present in the facility or there is a change in condition. The department also discussed the facility one on one supervision policy and requested an updated written policy be provided to the department. Additionally, the facility has increased licensee oversight with the regional director being on site monthly to ensure compliance. The department will also assist in expediting the administrator certificate for Veronica Morales. Report Continued on LIC 9099C In summary the facility agreed to the following and will provide the department of documentation of policy and procedure changes. Updated one on one supervision policy Documentation of most recent reporting requirements training and mandated reporter training to be completed every six months. Increased oversight of the facility by licensee as regional director will be on site once per month to ensure compliance. The department has offered TSP support and the facility voluntarily accepted. Department will make TSP referral. Per California Code of Regulations, Title 22 there were no deficiencies cited during today's meeting. An exit interview was conducted, and a copy of this report was mailed to the facility for signature.the state’s words, verbatim · CDSS document, Mar 19, 2024