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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002933
Report Date: 10/17/2024
Date Signed: 10/17/2024 04:43:39 PM

Document Has Been Signed on 10/17/2024 04:43 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:GREY MANORFACILITY NUMBER:
345002933
ADMINISTRATOR/
DIRECTOR:		RAMOS, KARLFACILITY TYPE:
740
ADDRESS:5216 NORTH AVETELEPHONE:
(916) 934-4234
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 6CENSUS: 6DATE:
10/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:55 PM
MET WITH:Liza SegubanTIME VISIT/
INSPECTION COMPLETED:
04:25 PM
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On 10/17/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a required annual inspection utilizing the full care tool. LPA met with Resident Care Coordinator and explained the purpose of the visit.

Facility has six residents in care with two on hospice services. Facility is currently licensed for six non-ambulatory with hospice waiver for six.

During today's visit, LPA and Resident Care Coordinator conducted a tour of the interior and exterior of the facility to ensure the health and safety of residents in care. Areas toured included but not limited to: residents bedrooms, bathroom, kitchen, backyard and the common areas.

LPA observed the sharps and toxins to be locked and inaccessible to residents in care. LPA observed medications to be locked and secure in the staff office. LPA observed facility to have two days of perishable and seven days of nonperishable foods.

File review conducted for six resident records and four personnel records. LPA observed personnel files to have the required documents needs on file. Additionally, LPA reviewed facility's quarterly Fire Drill, Infection Control Plan and Emergency Disaster Plan.

CARE tool completed with Resident Care Coordinator and found facility to be in substantial compliance.

As a result of today's inspection, no deficiencies observed.

Exit interview conducted and a copy of the report was provided.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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