045002441-6-15-2021-25-AS-KMKY-C43U2T-20210617151227

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 045002441
Report Date: 06/15/2021
Date Signed: 06/15/2021 12:07:58 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/15/2020 and conducted by Evaluator Misty Valencia

COMPLAINT CONTROL NUMBER: 25-AS-20201015102023

FACILITY NAME:	AMBER GROVE PLACE		FACILITY NUMBER:	045002441
ADMINISTRATOR:	MILLS, MARGARET		FACILITY TYPE:	740
ADDRESS:	3049 ESPLANADE		TELEPHONE:	(530) 826-3226
CITY:	CHICO	STATE: CA	ZIP CODE:	95973
CAPACITY:	70	CENSUS: 55	DATE:	06/15/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Administrator John Crowley		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Licensee did not ensure resident incontinent needs are being met
Licensee did not ensure facility is clean and odorless
Licensee did not ensure resident medications are given as prescribed

INVESTIGATION FINDINGS:

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On 06/15/2021, Licensing Program Analyst (LPA) Misty Valencia conducted an unannounced complaint investigation visit regarding the above allegations and met with Administrator John Crowley. Prior to initiating the complaint visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted Administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask and gloves. Additionally, LPA was screened by the front desk clerk. The purpose of the visit is to deliver findings regarding the allegations above

Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kevin Mknelly	TELEPHONE: (209) -81-1925
LICENSING EVALUATOR NAME: Misty Valencia	TELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 25-AS-20201015102023

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: AMBER GROVE PLACE	FACILITY NUMBER: 045002441
	VISIT DATE: 06/15/2021

NARRATIVE

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Licensee did not ensure resident incontinent needs are being met

LPA interviewed facility staff, residents, and reviewed records. During the investigation, it was determined that there was insufficient evidence to substantiate that licensee did not ensure residents incontinence needs are not being met. Interviews that were conducted concluded that staff and the residents all agree that there are never any inconstant items left in the trash cans or in the closets. LPA toured facility and did not observe any dirty depends in individual trash cans. LPA observed all dirty depends in the yellow bin stored in the utility closet. Based on statements and observations, this allegation cannot be proven. Therefore, this allegation is UNSUBSTANTIATED.

Licensee did not ensure facility is clean and odorless

LPA interviewed facility staff, residents, and reviewed records. During the investigation, it was determined that there was insufficient evidence to substantiate that licensee did not ensure facility is clean and odorless. Interviews that were conducted concluded that staff and the residents all agree that there have never been any odor that was not temporary in the facility. All reported that there are odors sometimes, but it is only after an accident and it is immediately cleaned, sanitized and aired out. LPA toured facility and did not observe any dirty floors, wheelchairs or odor in the building. Based on statements and observations, this allegation cannot be proven. Therefore, this allegation is UNSUBSTANTIATED.

continued on 9099-C

SUPERVISOR'S NAME: Kevin Mknelly	TELEPHONE: (209) -81-1925
LICENSING EVALUATOR NAME: Misty Valencia	TELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 25-AS-20201015102023

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: AMBER GROVE PLACE	FACILITY NUMBER: 045002441
	VISIT DATE: 06/15/2021

NARRATIVE

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Licensee did not ensure resident medications are given as prescribed

LPA interviewed facility staff, residents, and reviewed records. During the investigation, it was determined that there was insufficient evidence to substantiate that licensee did not ensure resident medications are given as prescribed. Interviews that were conducted concluded that staff and the residents all agree that there have never been any issues with medications. LPA determined that there is insufficient information available. Facility documents and statements indicate that R1’s PRN and prescribed medication were administered accordingly to doctor’s order. Based on statements and observations, this allegation cannot be proven. Therefore, this allegation is UNSUBSTANTIATED.

Based upon the information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred

An exit interview was conducted and a copy of this report, dated 06/10/202 was provided.

SUPERVISOR'S NAME: Kevin Mknelly	TELEPHONE: (209) -81-1925
LICENSING EVALUATOR NAME: Misty Valencia	TELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3