Gramercy Court

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 availablRead the full finding— CDSS inspection report, November 26, 2025 · control 27-AS-20251125172322

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. SubstantiatRead the full finding— CDSS inspection report, December 17, 2024 · control 27-AS-20241204153321

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 intervRead the full finding— CDSS inspection report, September 16, 2024 · control 27-AS-20240904110359

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... SubstantiatedRead the full finding— CDSS inspection report, May 6, 2024 · control 27-AS-20240405131806

On 8/15/23, Licensing Program Analyst (LPA) Tung Truong conducted an unannounced visit to this facility to commence a complaint investigation with the allegation above. LPA met with Interim Administrator Veronica Morales and explained the purpose of today’s visit. Throughout the course of the investigation, LPA conducted interviews and reviewed records. Based on the investigation, it was learned that resident (R1) has never been a resident at this facility. Further investigation revealed that R1 was a resident at Gramercy Court Skilled Nursing Facility (SNF) that is on the same campus. The interim administrator confirmed that R1 is a former resident of Gramercy Court SNF. As a result of this investigation, LPA finds the allegation above to be 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. Exit interview was conducted and a copy of the report was provided. UnfoundedRead the full finding— CDSS inspection report, August 15, 2023 · control 27-AS-20230809151539

On 6-22-23 at 9:54am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver findings for the allegations noted above. LPA met with Administrator Kendra Noonan and explained the purpose of the visit. During this investigation, LPA conducted interview with previous Administrator in charge and reviewed facility file documentation for resident1 (R1) and R2. LPA also reviewed facility’s resident roster list. Based on interview and record review, it was determined that R1 and R2 are not and have not been residents of this facility, and do not have additional records to indicate previous residency of this facility. As a result of this investigation, the preponderance of evidence standard is not met, and these allegations are UNFOUNDED. An exit interview was conducted Staff3 (S3). Administrator Kendra Noonan gave permission for S3 to sign in her absence at the time this report was delivered. A copy of this report was provided to S3. UnfoundedRead the full finding— CDSS inspection report, June 22, 2023 · control 27-AS-20230519101522

On 6-22-23, at 10:30am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to continue investigation and deliver findings for the allegation noted above. LPA met with Administrator Kendra Noonan and explained the purpose of the visit. During this investigation, LPA interviewed Administrator and additional witness. LPA also reviewed facility file documentation pertaining to resident1 (R1) including physician’s report, admissions agreement, incident reports, resident appraisal, fall risk assessments, mini-mental exam, progress notes, and additional assessments conducted by facility staff. Based on interviews and record reviews it was determined that R1 sustained a fall on 3-16-23 which resulted in hospitalization and eventual transfer to a local skilled nursing facility rehabilitation and treatment for bladder infection. It was further determined that R1's responsible party was attempting to be reamit R1 from skilled nursing but has not been re-admitted. {Cont. on 9099C}Read the full finding— CDSS inspection report, June 22, 2023 · control 27-AS-20230522140746