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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 045002441
Report Date: 12/15/2022
Date Signed: 12/15/2022 12:23:13 PM

Substantiated


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
10/21/2022 and conducted by Evaluator Kevin Mknelly
COMPLAINT CONTROL NUMBER: 25-AS-20221021165225
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: DATE:
12/15/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:John CrowleyTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Resident is not being allowed access to visitors.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 12/15/22 to deliver complaint findings. LPA met with Executive Director, John Crowley and explained the purpose of the visit. Prior to initiating the complaint visit, LPA completed required Department COVID-19 protocols. LPA completed a facility risk assessment upon arrival. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was screened by facility staff upon entering the facility.

The department reviewed client/resident records, facility records and conducted extensive interviews.
The department finds that the allegations cited above are substantiated.

Statements found that R1 had a leave from the facility with a family member for 5 days during a Covid-19 outbreak at the facility. Other family members expressed concerns to the facility Director about R1’s wellbeing. R1’s Power of Attorney (POA), asked that the Director prohibit a Zoom call with R1 on 6/6/22.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022
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 7
Control Number 25-AS-20221021165225
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: 12/15/2022
NARRATIVE
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Parties discussed the issue with the Long Term Care Ombudsman who advise that the POA did not have the power to restrict calls. R1 was allowed a Zoom call with the previously restricted family member the following day.

As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.

Report reviewed with Director . Copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 25-AS-20221021165225
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/05/2023
Section Cited
CCR
87468.1(a)(11)
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Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (11) To have their visitors, including ombudspersons and advocacy representatives, permitted to visit
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(Currently tele visits occur in lieu of some face-to-face visits)
Licensee will submit a plan for review of guardianship documents that responsible party possess to ensure third parties are asking for actions allowed to them in the guardiansip (POA, etc) and alternative
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privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon. This requirement was not met in the case of R1. This posed a potential risk to their personal rights
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 actions to be proposed to those parties to ensure resident right are upheld.
Licensee will submit the plan by the POC date of 1/5/23.
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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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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
10/21/2022 and conducted by Evaluator Kevin Mknelly
COMPLAINT CONTROL NUMBER: 25-AS-20221021165225

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: DATE:
12/15/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:John CrowleyTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Resident is not allowed to leave the facility.
INVESTIGATION FINDINGS:
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On 12/15/22), Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with clinical staff. Prior to initiating the complaint visit, LPA completed required COVID-19 testing protocols. Upon arrival, 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. Additionally, LPA was screened with temperature at the facility.

LPA conducted records review and extensive interviews.
LPA is unable to find and or meet the preponderance, per policy.

R1 was allowed to leave for outings on multiple occasions. The facility at time questioned the plan for some outings for R1 with one family member. On 2 occasions R1 left the facility with that family member who was questioned. Eventually a conservatorship was established which restricts R1's leave from the
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022
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 7
Control Number 25-AS-20221021165225
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: 12/15/2022
NARRATIVE
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facility under certain conditions.

As a result of this investigation, LPA finds allegation to be (US)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.

Exit interview with administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 7
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
10/21/2022 and conducted by Evaluator Kevin Mknelly
COMPLAINT CONTROL NUMBER: 25-AS-20221021165225

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: DATE:
12/15/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:John CrowleyTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Resident appears over medicated.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 10/15/21 to provide complaint findings. LPA met with staff and explained the purpose of the visit. Prior to initiating the 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. Upon arrival LPA 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. Additionally, LPA were screened by facility staff upon entering the facility.

LPAs reviewed resident records, facility records, inspections and conducted interviews.
The department finds that facility met Tittle 22 requirements.

R1 was found to be receiving medications as precribed by their physician.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 25-AS-20221021165225
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: 12/15/2022
NARRATIVE
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Any changes of condition for R1 or possible medication reactions are communicated with R1's physician.
R1 does at times have fluctuations in their physical and cognitive ability.

This agency has investigated the above complaint allegations. We have found that the complaint is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

Exit interview conducted and report provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 7