045002441-8-3-2023-59-AS-KHOS-CV6N73-20230829101205

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 045002441
Report Date: 08/03/2023
Date Signed: 08/03/2023 12:25:32 PM

Unfounded

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
03/03/2023 and conducted by Evaluator Kerry Hiratsuka

COMPLAINT CONTROL NUMBER: 59-AS-20230303103754

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: 55	DATE:	08/03/2023
		UNANNOUNCED	TIME BEGAN:	11:50 AM
MET WITH:	Brenda Reitz		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff are overmedicating resident

INVESTIGATION FINDINGS:

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LPAs Hiratsuka and Boyles, conducted this visit to deliver the results of the investigation above.

LPA Hiratsuka investigated the allegation “Staff are overmedicating resident."

LPA Hiratsuka interviewed staff, complainant, and reviewed resident’s file. LPA was unable to interview resident because resident moved out.

The medication in question was prescribed as an “as needed,” medication and was for anxiety. The prescription was to give every six hours as needed. The facility filled the prescription twice for a total of 60 doses over an eight month time span. Complainant stated the resident was overdosed based on the resident being very lethargic in the morning time.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kerry Hiratsuka	TELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023

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

LIC9099 (FAS) - (06/04)

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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
03/03/2023 and conducted by Evaluator Kerry Hiratsuka

COMPLAINT CONTROL NUMBER: 59-AS-20230303103754

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: 55	DATE:	08/03/2023
		UNANNOUNCED	TIME BEGAN:	11:50 AM
MET WITH:	Brenda Reitz		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff are not wearing mask per COVID-19 guidelines

INVESTIGATION FINDINGS:

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LPAs Hiratsuka and Boyles, conducted this visit to deliver the results of the investigation above.

LPA Hiratsuka investigated the allegation “Staff are not wearing mask per COVID-19 guidelines."

LPA Hiratsuka interviewed staff, complainant, and toured the facility. During the tour prior to faciities being allowed to not wear masks LPA observed all staff wearing masks properly. Interviews with staff stated they were shown how to wear masks and made sure they wore them properly. Complainant stated the staff were either not wearing them or the face was not completely covered.
Based on the above, LPA cannot prove or disprove the allegation based on each side's version.

Due to the information gathered, LPA cannot determine the allegations: Staff are not wearing mask per COVID-19 guidelines. LPA finds allegation to be 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.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kerry Hiratsuka	TELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023

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

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 59-AS-20230303103754

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: 08/03/2023

NARRATIVE

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The facility does have the required medication administration record for as needed medication and it showed no more than one pill was given in a 24-hour period and there were days the medication was not given. The record shows a total of 25 pills were given to the resident and 35 were released to the responsible party when the resident moved out. The record also showed the medication was given at 2:06am one morning and 5:45am the next day which are the days the complaint stated the resident was overdosed. Interviews with staff stated the resident did not like getting up early in the morning and would normally get ready for the day after 9:00am or as late as 10:00am. The medication in question has side effects and one is being lethargic. The complainant did not seek medical attention or any tests to address the allegation.

Based on the record review and interviews the allegation is unfounded.

“This agency has investigated the complaint alleging; Staff are overmedicating resident. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis."

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kerry Hiratsuka	TELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023

LIC9099 (FAS) - (06/04)

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