Gramercy Court.

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.

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.

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.

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} 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 26 27 28 29 30 31 32 {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.

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 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 26 27 28 29 30 31 32 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.

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.

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.

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. 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 26 27 28 29 30 31 32 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.

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 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 26 27 28 29 30 31 32 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.