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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 312700994
Report Date: 11/07/2024
Date Signed: 11/07/2024 12:17:03 PM

Unsubstantiated


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
10/29/2024 and conducted by Evaluator Cassandra Mikkelson
COMPLAINT CONTROL NUMBER: 59-AS-20241029115916
FACILITY NAME:AMETHYST GROVE ASSISTED LIVINGFACILITY NUMBER:
312700994
ADMINISTRATOR:ALLEN, MARCFACILITY TYPE:
740
ADDRESS:2145 CUMBERLAND LOOPTELEPHONE:
(916) 250-1128
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:6CENSUS: 5DATE:
11/07/2024
UNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Alex BotTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Facility staff are not providing assistance with residents' ADLs.
Facility staff are not following physician's orders for medications.
Facility staff are not ensuring residents have a safe and comfortable environment.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPAs) Cassandra Mikkelson and Michael Hood arrived at the facility and met with Administrator, Alex Bot, to deliver findings regarding the complaint allegations listed above.

During the course of the investigation, LPAs conducted interviews with staff and residents, reviewed medication records, and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

***Report continued on 9099-C***
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
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 5
Control Number 59-AS-20241029115916
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: AMETHYST GROVE ASSISTED LIVING
FACILITY NUMBER: 312700994
VISIT DATE: 11/07/2024
NARRATIVE
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Allegation: Facility staff are not providing assistance with residents' ADLs.

Interviews conducted with residents R1, R2, R3, and R4 indicated that they are doing well at the facility. R1 stated that care is “good” at the facility, and they receive transfer assistance and toileting assistance. R1 stated that the facility is very accommodating with visitors. R2 stated that their care needs are being met at the facility and they receive assistance with showers. R2 stated that they are able to make it to appointments. R2 stated that they use their walker to go to the toilet, but staff provide assistance as needed. R2 stated that staff are prompt to respond to their call button. R1 and R2 stated that they have no concerns regarding the operations of the facility.

Interviews with staff members S1, S2, and Administrator indicated that they have no concerns regarding care being provided at the facility. S1, S2, and Administrator stated that they have never witnessed a resident left in soiled clothing at the facility. Administrator stated that residents who receive incontinence care at the facility receive checks every four (4) hours during the day and every hour during the night. S2 stated that residents in need of incontinence care are checked every two (2) hours or more than every two (2) hours to observe if the resident soiled themselves.
During visit, LPAs did not observe any residents in need of care and not receiving care by facility staff.

Allegation: Facility staff are not ensuring residents have a safe and comfortable environment.

Relevant party reported that facility had painted the interior of the facility and paint fumes from the job created a hazardous environment for the residents in care.

Interview with Administrator indicated that door trims were painted on approximately 10/25/2024 for all shared bathrooms and resident bedrooms. Administrator stated that there was only an odor detected when coming close to the door trim and there were no toxins in relation to the paint job. Administrator stated that the smell only lasted thirty (30) to forty (40) minutes and an individual would not be able to smell the paint from three (3) feet away. Administrator stated that painters came twice but did not actually paint interior until approximately 10/25/2024. Administrator stated that masking was used to catch any paint that fell. Interview with S1 indicated that they were not present at the facility during paint job. Interview with S2 indicated that the paint on the doorways “did smell strong,” but staff opened windows and the smell didn’t last. S2 stated it was “not even five (5) minutes” before the smell went away and the facility used “fast-acting” paint
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC9099 (FAS) - (06/04)
Page: 2 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
10/29/2024 and conducted by Evaluator Cassandra Mikkelson
COMPLAINT CONTROL NUMBER: 59-AS-20241029115916

FACILITY NAME:AMETHYST GROVE ASSISTED LIVINGFACILITY NUMBER:
312700994
ADMINISTRATOR:ALLEN, MARCFACILITY TYPE:
740
ADDRESS:2145 CUMBERLAND LOOPTELEPHONE:
(916) 250-1128
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:6CENSUS: 5DATE:
11/07/2024
UNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Alex BotTIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not seek medical attention for resident in a timely manner.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
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13
Licensing Program Analyst (LPAs) Cassandra Mikkelson and Michael Hood arrived at the facility and met with Administrator, Alex Bot, to deliver findings regarding the complaint allegation listed above.

During the course of the investigation, LPAs conducted interviews with staff and residents, reviewed medication records, and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

***Report continued on 9099-C***
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
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 5
Control Number 59-AS-20241029115916
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: AMETHYST GROVE ASSISTED LIVING
FACILITY NUMBER: 312700994
VISIT DATE: 11/07/2024
NARRATIVE
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Allegation: Staff did not seek medical attention for resident in a timely manner.

Interview with relevant party indicated that resident (R1) did not receive medical attention for a recent UTI. Relevant party stated that R1 received a home test for UTI, which had a positive result. Relevant party stated that they filled a prescription for Depakote that they already had to treat R1’s UTI and therefore did not seek medical attention. LPAs were unable to obtain any discharge papers regarding R1’s UTI diagnosis for review.

Based on interviews conducted, observations, and records reviewed, the above allegation is found to be UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

Exit interview was conducted with OD. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 59-AS-20241029115916
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: AMETHYST GROVE ASSISTED LIVING
FACILITY NUMBER: 312700994
VISIT DATE: 11/07/2024
NARRATIVE
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Interviews with resident R1, R2, R3, and R4 indicated that they were doing good at the facility. No interview with residents indicated any concerns regarding paint fumes. During visit, LPAs did not observe paint fumes in the interior of the facility.

Allegation: Facility staff are not following physician's orders for medications.

Relevant party stated that the facility was providing R1 with melatonin even though their Power of Attorney told the facility not to provide melatonin to R1.

LPAs reviewed R1’s medication records and medications. R1’s medication records showed that R1 had a prescription for melatonin that was to be on hold until 11/30/2024. LPAs observed a MAR for R1 which did not show that melatonin was given. LPAs could not conduct a medication count for R1’s melatonin as it had been removed from the facility.

LPAs reviewed a prescription for R1’s Depakote. Facility was able to provide a doctor’s order for R1’s Depakote during visit.

Based on interviews conducted, observations, and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation 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 was conducted with Administrator. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5