045002441-1-26-2023-25-AS-KHOS-CNNP9Z-20230202100757

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 045002441
Report Date: 01/26/2023
Date Signed: 01/26/2023 10:34:27 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 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
11/17/2022 and conducted by Evaluator Rebecca Knight

COMPLAINT CONTROL NUMBER: 25-AS-20221117102042

FACILITY NAME:	AMBER GROVE PLACE		FACILITY NUMBER:	045002441
ADMINISTRATOR:	CROWLEY, JOHN		FACILITY TYPE:	740
ADDRESS:	3049 ESPLANADE		TELEPHONE:	(530) 826-3226
CITY:	CHICO	STATE: CA	ZIP CODE:	95973
CAPACITY:	70	CENSUS:	DATE:	01/26/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	John Crowley - Executive Director		TIME COMPLETED:	10:45 AM

ALLEGATION(S):

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Facility staff did not properly handle potentially infectious material. - SUBSTANTIATED

INVESTIGATION FINDINGS:

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01/26/2023 10:00 AM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with Executive Director John Crowley. Prior to initiating the visit, LPA completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 mask, gloves.
During the course of the investigation the executive director and 6 staff were interviewed. LPA received the following documents: Resident list, staff list with telephone numbers, infection control plan, related incident reports, photograph.

Continued on LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

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 6

Control Number 25-AS-20221117102042

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: AMBER GROVE PLACE	FACILITY NUMBER: 045002441
	VISIT DATE: 01/26/2023

NARRATIVE

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Facility staff did not properly handle potentially infectious material – SUBSTANTIATED

It was reported that staff emptied a resident’s trash can that contained vomit without wearing gloves.

LPA review of photograph of small wicker type trash can with a plastic liner that contained blue cups and napkins that contained what appears to be vomit.

On 01/26/2023 LPA went into R1’s room and viewed the trash can in R1’s room which verifies this is the same trash can as in the original photograph.

6 of 6 staff interviewed stated they wear gloves when emptying trash cans and handling potentially infectious materials.

Executive Director stated staff wear gloves when handling potentially infectious materials.

It was determined that staff did not put on gloves before emptying a resident's trash can that contained vomit.This allegation is substantiated.

Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview was conducted and the report was provided to Executive Director John Crowley.

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 25-AS-20221117102042

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: AMBER GROVE PLACE	FACILITY NUMBER: 045002441
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/26/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/09/2023 Section Cited CCR 87470(a)(4)(a)(1)	1 2 3 4 5 6 7	87470(a)(4)(a)(1) Infection Control Requirements – (a) A licensee shall ensure that infection control practices are maintained as follows: (4) All facility staff and volunteers shall use gloves as a protective barrier to prevent the spread of potential infection as specified below. (A) Gloves shall always be worn when: (1) Coming into contact with blood or body fluids such as saliva, stool, vomit, or urine. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee agrees to provide training for all direct care staff on the requirement and proper use of gloves when handling potentially infectious materials. Licensee will conduct the training and provide LPA with attendance sheet that has been signed by all staff.
	8 9 10 11 12 13 14	Based on observation and document review it was determined that the licensee failed to ensure that staff were wearing gloves when handling potentially infectious materials. This poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14	The proof of correction is to be received by LPA Knight by 02/10/2023.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 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
11/17/2022 and conducted by Evaluator Rebecca Knight

COMPLAINT CONTROL NUMBER: 25-AS-20221117102042

FACILITY NAME:	AMBER GROVE PLACE		FACILITY NUMBER:	045002441
ADMINISTRATOR:	CROWLEY, JOHN		FACILITY TYPE:	740
ADDRESS:	3049 ESPLANADE		TELEPHONE:	(530) 826-3226
CITY:	CHICO	STATE: CA	ZIP CODE:	95973
CAPACITY:	70	CENSUS:	DATE:	01/26/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	John Crowley - Executive Director		TIME COMPLETED:	10:45 AM

ALLEGATION(S):

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Facility staff did not properly dispense medication to resident. - UNSUBSTANTIATED
Facility staff are not following Universal Precautions. - UNSUBSTANTIATED
Facility staff co-mingled residents during an outbreak at the facility. - UNSUBSTANTIATED

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

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 6

Control Number 25-AS-20221117102042

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: AMBER GROVE PLACE	FACILITY NUMBER: 045002441
	VISIT DATE: 01/26/2023

NARRATIVE

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Facility staff did not properly dispense medication to resident. – UNSUBSTANTIATED

It was reported that a care staff picked up a pill from a surface in a resident’s room without gloves on and handed it to the resident.

4 of 6 staff stated they would not give the pill to the resident but would give the pill to the med tech so they could dispense a new pill. 1 of 6 staff stated they would not give the pill to the resident and would notify their supervisor. 1 of 6 staff stated they would put on a glove, place the pill in a med cup and hand it to the resident. 6 of 6 staff interviewed stated they wear gloves when handling medications.

Executive Director stated staff wear gloves when dispensing or handling medications. They wouldn’t hand a pill; they would pop the blister pack into the cup and hand it to the resident wearing gloves. They would wash their hand before and after.

There is not enough evidence to substantiate this incident. It was determined that the facility is properly dispensing medication to residents. This allegation is unsubstantiated.

Facility staff are not following universal precautions. – UNSUBSTANTIATED

It was reported that staff did not wash their hands when entering and exiting a resident room.

During LPA tour of the facility on 01/26/2023 LPA observed staff practicing universal precautions.

6 of 6 staff stated they wash or disinfect their hands when entering and exiting a resident room. 5 of 6 staff stated they had been trained on universal precautions by a mix of videos, staff training sessions and job shadowing, 1 of 6 staff stated that their job duties did not require them to be trained on universal precautions. 4 of 6 staff stated they had never seen other staff not practicing universal precautions, 2 of 6 staff stated they had witnessed other staff not practicing universal precautions.

Executive Director stated that staff absolutely follow universal precautions and the facility has completed monthly staff meetings and train on infection control and universal precautions during those staff meetings.

It was determined that the facility is following universal precautions and conducts staff training on universal precautions. This allegation is unsubstantiated.

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 25-AS-20221117102042

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: AMBER GROVE PLACE	FACILITY NUMBER: 045002441
	VISIT DATE: 01/26/2023

NARRATIVE

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Facility staff co-mingled residents during an outbreak at the facility. – UNSUBSTANTIATED

LPA reviewed an incident report dated 11/15/2022 that reported the facility had a GI outbreak that started on 11/12/2022, 17 residents were symptomatic. As of 11/15/2022 the outbreak had abated.

4 of 6 staff stated during a recent Norovirus outbreak infected residents were not co-mingling with non-infected residents. 1 of 6 staff stated that infected residents were co-mingling with non-infected residents because by the time they were symptomatic they had already been in the community. 1 of 6 staff stated they did not know if infected residents were not co-mingling with non-infected residents.

Executive Director stated We did our best, we have a couple of residents that were in shared rooms and we were moving the resident who was not infected out of the rooms to try to prevent them getting infected. This is memory care and there are residents who were infected who we could not keep in their rooms.

It was determined that the facility practiced reasonable efforts to keep non-infected residents from being exposed to infected residents during the GI outbreak in a memory care unit. This 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 John Crowley.

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

LIC9099 (FAS) - (06/04)

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