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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 045002441
Report Date: 10/18/2023
Date Signed: 10/18/2023 12:33:11 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/30/2023 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 59-AS-20230530143145
FACILITY NAME:AMBER GROVE PLACEFACILITY NUMBER:
045002441
ADMINISTRATOR:REITZ, BRENDAFACILITY TYPE:
740
ADDRESS:3049 ESPLANADETELEPHONE:
(530) 826-3226
CITY:CHICOSTATE: CAZIP CODE:
95973
CAPACITY:70CENSUS: DATE:
10/18/2023
UNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Brenda ReitzTIME COMPLETED:
12:40 PM
ALLEGATION(S):
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Resident sustained injuries due to lack of supervision.
INVESTIGATION FINDINGS:
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LPA Hiratsuka conducted this visit to deliver the results of the investigation above. LPA met with Brenda Reitz, Executive Director, and spoke to Tara Killinger, Vice President of Operations on the phone.

During the course of the investigation the executive director, former staff, and current staff were interviewed. Medical records and facility records were reviewed.

The resident in question had several falls during the duration of the time at the facility. Per the regulations the resident shall be accessed each time there a change in condition and written plans of care shall be adjusted accordingly. Record reviews show this did not happen. Interviews showed interventions were discussed but they were not implemented and there is no documentation stating why the interventions were not implemented.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/30/2023 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 59-AS-20230530143145

FACILITY NAME:AMBER GROVE PLACEFACILITY NUMBER:
045002441
ADMINISTRATOR:REITZ, BRENDAFACILITY TYPE:
740
ADDRESS:3049 ESPLANADETELEPHONE:
(530) 826-3226
CITY:CHICOSTATE: CAZIP CODE:
95973
CAPACITY:70CENSUS: DATE:
10/18/2023
UNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Brenda ReitzTIME COMPLETED:
12:40 PM
ALLEGATION(S):
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Facility not releasing information about resident to responsible party.
INVESTIGATION FINDINGS:
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LPA Hiratsuka conducted this visit to deliver the results of the investigation above. LPA met with Brenda Reitz, Executive Director, and spoke to Tara Killinger, Vice President of Operations on the phone.

During the course of the investigation the executive director, former staff, and current staff were interviewed. Medical records and facility records were reviewed.

Tara Killinger, Vice President of Operations, produced an email conversation with the responsible party stating the incident in question was discussed with the responsible party when the incident occurred. The issue is about the report being released in writing and to whom the written report was to be released to. And the email did confirm the facility notified the responsible party both verbally and in writing.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 59-AS-20230530143145
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: AMBER GROVE PLACE
FACILITY NUMBER: 045002441
VISIT DATE: 10/18/2023
NARRATIVE
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Title 22 Regulations, Report Requirements state: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.

The facility produced documentation they spoke to the responsible party. There was another person related to the resident who requested the written report and wanted the same incident report that was submitted to Community Care Licensing Division. Title 22 Regulations state the information is to be released to the responsible party only and not a third party. There was no written consent produced from the responsible party to allow the third party to receive the information. Also, Title 22 Regulations does not state the incident report submitted to Community Care Licensing Division shall match the one released to the responsible party. LPA discussed with Executive Director Brenda Reitz, and Tara Killinger, Vice President of Operations about reporting requirements and what may or may not be released.

Because LPA cannot prove or disprove what is required to be reported to responsible parties and what was discussed for this incident, the allegation is unsubstantiated.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED.

An exit interview was conducted. A copy of the report was provided to facility executive director Brenda Reitz.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 59-AS-20230530143145
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: AMBER GROVE PLACE
FACILITY NUMBER: 045002441
VISIT DATE: 10/18/2023
NARRATIVE
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The fall in question occurred in May 2023. The caregiver went to check on the resident in the morning and the resident did not want to get up. Per the facility report, about an hour later a housekeeper heard the resident yelling for help and that is the fall that resulted in the injury. The written care of plan did not indicate how frequently the resident needed to be checked on and there were no fall prevention interventions specific to the resident in question.

As a result of this investigation, the Department finds the allegation above to be Substantiated. A finding that the complaint is Substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. At the time of the complaint visit, an immediate civil penalty of $500 shall be assessed for a violation of California Code of Regulations Section 87463(a). The licensee was informed that a civil penalty was under review and may be assessed at a future date according to Health and Safety Code 1569.49.

Exit interview conducted. A copy of the report has been issued. Appeal Rights provided. Brenda Reitz signature on this report acknowledges receipt of the Appeal Rights
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 59-AS-20230530143145
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: AMBER GROVE PLACE
FACILITY NUMBER: 045002441
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
10/19/2023
Section Cited
CCR
87463(a)
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Reappraisals. The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition.
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By 10/19/2023, the licensee shall submit in writing a facility fall prevent plan that shall at minimum include documentation of meetings with responsible parties, documenting change of conditions, discussion of fall prevent measures with responsible party, and overall documentation of the resident.
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Based on observation and document review it was determined that the licensee failed to ensure the appraisal was updated and the written plan of care and after each fall. This poses a potential health and safety risk to residents in care.
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IMMEDIATE $500 CIVIL PENALTY ISSUED.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5