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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 045002441
Report Date: 03/19/2024
Date Signed: 03/19/2024 10:44:58 AM

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
05/01/2023 and conducted by Evaluator Donna Gurriere
COMPLAINT CONTROL NUMBER: 59-AS-20230501133628
FACILITY NAME:AMBER GROVE PLACEFACILITY NUMBER:
045002441
ADMINISTRATOR:CROWLEY, JOHNFACILITY TYPE:
740
ADDRESS:3049 ESPLANADETELEPHONE:
(530) 826-3226
CITY:CHICOSTATE: CAZIP CODE:
95973
CAPACITY:70CENSUS: 61DATE:
03/19/2024
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:BRENDA REITZTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Facility failed to follow care plan leading to a resident developing pressure injuries.
Facility is retaining residents beyond their level of care.
Facility staff are not supervising residents.
INVESTIGATION FINDINGS:
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On 03/19/24, Donna Gurriere, Licensing Program Analyst (LPA) arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 05/01/23. LPA Gurriere met with Brenda Reitz, Administrator, and explained the purpose of the visit.

Facility failed to follow care plan leading to a resident developing pressure injuries.

During the interview process, numerous documents were obtained. Documents included the Physician’s Report, Medication Administrative Records (MARs), Home Health records, Hospice records, Resident Care Plan, and Physicians Orders.


continued
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024
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 10
Control Number 59-AS-20230501133628
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: 03/19/2024
NARRATIVE
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continued

During the investigation process, management, numerous staff persons, a physician and a nurse were interviewed regarding the resident’s condition. The resident (Resident 1) was not interviewed, as she has since passed away. It was reported that the resident developed several pressure injuries while in care.

The following information was provided regarding the resident: On 07/11/22 the resident was seen by her physician, and it was noted that the resident had a skin breakdown in her groin area and topical cream was prescribed. On 07/14/22 the first notation of a breakdown was on the resident’s “bottom.” It was stated in the care notes that the “resident has a sore on her bottom that is getting bad, we are going to rotate her while in bed and please apply cream after toileting.” On 07/17/22 it was documented that the resident had an “open” wound on her coccyx and blisters on her heel. The resident was not seen by the physician until 07/29/22 and at that time, the physician opened the resident to Home Health for wound care. The resident did not get professional medical care from the physician or a home health nurse for numerous days for several pressure injuries.

Based on investigation observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D.

Appeal Rights were explained and provided to the facility representative listed above and an exit interview was conducted. If any of the cited deficiencies are not corrected by the noted due date, civil penalties may be assessed.

SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024
LIC9099 (FAS) - (06/04)
Page: 8 of 10
Control Number 59-AS-20230501133628
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: 03/19/2024
NARRATIVE
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Facility is retaining residents beyond their level of care.

During the interview process, numerous documents were obtained. Documents included the Physician’s Report, Medication Administrative Records (MARs), Home Health records, Hospice records, Resident Care Plan, and Physicians Orders.

During the investigation process, management, numerous staff persons, a physician and a nurse were interviewed regarding the resident’s condition. The resident (Resident 1) was not interviewed, as she has since passed away.

It was reported that the resident developed several pressure injuries while in care as noted in the above-mentioned report. It was indicated that for numerous days, the resident had several pressure injuries that were not staged by a physician or an appropriately skilled professional, as required. If the licensee chooses to retain a resident with pressure injuries, the licensee shall have the pressure injuries staged and shall ask the licensing agency for an exception to retain the resident if the pressure injuries are a Stage 3 or 4. It is noted that at the time, when the resident had pressure injuries, initially the resident was not receiving home health care or hospice services for several days. It was determined that the facility failed to obtain an exception for the resident when it was determined that the resident had pressure injuries (unstaged), which is a prohibited and/or restricted health condition.

According to the Mayo Clinic a pressure ulcer is, “A localized injury to the skin and /or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear”. The National Pressure Ulcer Advisory Panel (NPUAP) advises that “Unstageable wounds are either Stage 3 or 4 ulcers that cannot definitively be placed in either of these stages due to eschar (dry scab or mass of dead tissue covering a wound) that obstructs clear observation of the wound. Therefore, by general medical consensus, a wound diagnosed as an unstageable wound is either a Stage 3 or 4 wound and, as such, is to be treated as a prohibited health condition.”
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024
LIC9099 (FAS) - (06/04)
Page: 9 of 10
Control Number 59-AS-20230501133628
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: 03/19/2024
NARRATIVE
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Based on investigation observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D.

Appeal Rights were explained and provided to the facility representative listed above and an exit interview was conducted. If any of the cited deficiencies are not corrected by the noted due date, civil penalties may be assessed.



Facility staff are not supervising residents.

During the interview process, numerous documents were obtained. Documents included the Physician’s Report, Medication Administrative Records (MARs), Resident Care Plan, and Physicians Orders.

During the investigation process, management, and numerous staff persons, were interviewed. The resident (Resident 2) was not interviewed, as he has since passed away. It was reported that the resident was a fall risk. Physical therapy was brought in for the resident between November-December 2022 and documented that the resident improved in his ability to ambulate with a walker but was noted “as ambulating with a standby assist.” Prior to the resident’s fall on 06/12/22, the resident had five falls documented between 01/22-05/23/22. The resident was sent to the hospital for the fall on 05/23/22 with a hematoma to his forehead. The charting notes state that the resident was very unsteady, was wandering (as usual) and needed repeat reminders to use his walker.

On 06/12/22 the resident was sent to the hospital after sustaining an unwitnessed fall in the hallway of the facility. The resident was diagnosed with and underwent surgery to repair a left femoral neck fracture. Some staff reported that the resident had a shuffled step, was unsteady with his walker or would walk very rapidly with his walker and needed an escort or additional supervision. However, other staff reported that the resident only needed reminders to use his walker but was otherwise able to ambulate without assistance. It was reported that the facility was unable to provide a fall risk care plan that was updated prior to 06/12/22. When a resident is at fall risk, the facility shall complete a fall risk care plan for the resident. There was no written fall risk care plan addressing the resident’s falls.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024
LIC9099 (FAS) - (06/04)
Page: 10 of 10
Control Number 59-AS-20230501133628
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: 03/19/2024
NARRATIVE
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Based on investigation observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D.

Appeal Rights were explained and provided to the facility representative listed above and an exit interview was conducted. If any of the cited deficiencies are not corrected by the noted due date, civil penalties may be assessed.



An immediate civil penalty in the amount of $500.00 assessed for R2 sustaining a serious bodily injury while in care at this facility.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 10
Control Number 59-AS-20230501133628
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: 03/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/20/2024
Section Cited
CCR
87464(d)
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Basic Services - A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal and providing the other basic services specified below, either directly or through outside resources.
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The administrator agrees to submit to the licensing agency how this type of deficiency will be avoided in the future.
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This requirement was not met as evidenced by: Based on interviews by numerous persons, and records reviewed, the licensee did not ensure that the resident received care in a timely manner for her pressure injuries. This poses an immediate risk to residents in care.
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Type A
03/20/2024
Section Cited
CCR
87616(a)
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Exceptions for Health Conditions
As specified in Section 87209, Program Flexibility, the licensee may submit a written exception request if he/she agrees that the resident has a prohibited and/or restrictive health condition but believes that the intent of the law can be met through alternative means.
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The administrator agrees to submit to the licensing agency a statement that she understands the requirement to request an exception when a resident is staged with a pressure wound, Stage 3 or 4.
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This requirement was not met as evidenced by: Based on interviews by numerous persons, and records reviewed, the licensee did not ensure that an exception was in place for a resident that had pressure injuries. This poses an immediate risk to residents in care.
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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: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 10
Control Number 59-AS-20230501133628
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: 03/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/20/2024
Section Cited
HSC
1569.269(a)(6)
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Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (6) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
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The administrator agrees to assess all residents that are a fall risk. Training shall be provided to care providers regarding prevention practices of residents that are a fall risk. The administrator agrees to submit to the licensing agency the materials used to train the care providers and a sign in sheet of those that were trained.
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This requirement was not met as evidenced by interviews and documentation review. The licensee failed to comply with the regulation cited above. A fall risk care plan was not in place. This poses an immediate health and safety risk to residents in care.
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An immediate civil penalty in the amount of $500.00 assessed for R2 sustaining a serious bodily injury while in care at this facility.
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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: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 10
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
05/01/2023 and conducted by Evaluator Donna Gurriere
COMPLAINT CONTROL NUMBER: 59-AS-20230501133628

FACILITY NAME:AMBER GROVE PLACEFACILITY NUMBER:
045002441
ADMINISTRATOR:CROWLEY, JOHNFACILITY TYPE:
740
ADDRESS:3049 ESPLANADETELEPHONE:
(530) 826-3226
CITY:CHICOSTATE: CAZIP CODE:
95973
CAPACITY:70CENSUS: 61DATE:
03/19/2024
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:BRENDA REITZ/LORI WHITBURNTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Facility did not provide proper care and supervision resulting in the deaths of two residents.
A facility staff was working while intoxicated.
The facility is unsanitary.
Facility staff are not meeting residents’ hygiene needs.
Facility runs out of supplies.
INVESTIGATION FINDINGS:
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On 03/19/24 Donna Gurriere, Licensing Program Analyst (LPA) arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 05/01/23. LPA Gurriere met with Brenda Reitz and Lori Whitburnand explained the purpose of the visit.

Facility did not provide proper care and supervision resulting in the deaths of two residents.

During the interview process, numerous documents were obtained. Documents included the Physician’s Report, Medication Administrative Records (MARs), Home Health records, Hospice records, Resident Care Plan, and Physicians Orders.

continued
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024
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 10
Control Number 59-AS-20230501133628
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: 03/19/2024
NARRATIVE
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During the investigation process, management, numerous staff persons, a physician and others were interviewed. It was reported that the resident (Resident 1) had severe dementia, anxiety issues and quit wanting to eat. The resident had pneumonia right before she had pressure wounds. The resident’s physician reported that once a resident contracts an infection like pneumonia, it can be very hard to come back from. The resident’s death certificate stated the cause of death as Cardiopulmonary Arrest with Nutritional Deficiency, Anorexia and Dementia as underlying causes. It was stated that there was not a preponderance of evidence found to substantiate that the resident’s death was a result of the pressure injury or neglect.

It was reported that the resident (Resident 2) had an unwitnessed fall at the facility and suffered a left femoral neck fracture. After surgery, the resident was transferred to a Post-Acute Skilled Nursing facility for rehabilitation and while there, suffered another fall. The resident was transferred to the hospital with confusion, lethargy, and laceration. In addition, scans showed another fracture and concern for a possible subarachnoid hemorrhage. It cannot be substantiated that the resident’s death was a result of neglect or lack of care and supervision on the part of the facility.

A facility staff was working while intoxicated.
During the investigation process, management, and numerous staff persons, were interviewed. The residents were not interviewed due to their dementia status. It was reported that there could have been a person that came to the facility to work and was allegedly intoxicated. Another staff person contacted management to advise of the allegation. The manager arrived at the facility and as a precaution, requested that the staff person in question be sent home. It was stated that after the incident, the staff person was terminated from her position. It was reported that there was not an issue with resident care during the time of the incident.

The facility is unsanitary.
During the investigation process, management, and numerous staff persons, were interviewed. The residents were not interviewed due to their dementia status. The allegation was stated to report that soiled adult briefs are left unattended in resident rooms and that sheets are not changed when soiled. Overall, staff reported that the staff bag up the soiled adult briefs and dispose of them in designated trash cans. In addition, it was reported that sheets are changed as needed and when soiled.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 10
Control Number 59-AS-20230501133628
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: 03/19/2024
NARRATIVE
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Facility staff are not meeting residents’ hygiene needs.
During the investigation process, management, and numerous staff persons, were interviewed. The residents were not interviewed due to their dementia status. It was reported by nearly all staff persons that they are meeting the residents’ hygiene needs, as they follow a showering schedule. Staff reported that if a resident refuses to shower, they will try again later. It was stated that some of the residents will refuse their shower day, which is the resident’s right to do so.


Facility runs out of supplies.
During the investigation process, management, and numerous staff persons, were interviewed. The residents were not interviewed due to their dementia status. The allegation indicated that the facility does not have enough disposable wet wipes available when changing the adult briefs of residents. An inventory list was obtained and reviewed, and the list indicated that the facility is ordering wet wipes to use on the residents. Overall, staff confirmed that wet wipes are available when changing a resident and providing care and supervision.

Although the above allegations mentioned may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and all of the above findings are Unsubstantiated.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 10