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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700994
Report Date: 02/22/2023
Date Signed: 02/22/2023 02:37:13 PM


Document Has Been Signed on 02/22/2023 02:37 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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



FACILITY NAME:AMETHYST GROVE ASSISTED LIVINGFACILITY NUMBER:
312700994
ADMINISTRATOR:ALLEN, MARCFACILITY TYPE:
740
ADDRESS:2145 CUMBERLAND LOOPTELEPHONE:
(916) 743-4950
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:6CENSUS: 6DATE:
02/22/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Nayely Gilbert, House ManagerTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct a case management visit. LPA met with house manager Nayely Gilbert during today's inspection. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Masks.

LPA received a report from the facility in concerns to a incident that occurred on 2/11/23. Resident has an order for a PRN medication, in which staff gave resident a double dose. Staff had a mis-communication and gave resident 2 doses instead of 1 dose, as directed by physician. House manager states facility completed training for facility staff concerning medication error. Resident had no adverse effect, and hospice agency and responsible party was informed. Due to information gathered deficiencies were cited as a result of investigation.

Deficiencies cited on 809-C. Appeal rights given.

Exit interview provided.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 02/22/2023 02:37 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926


FACILITY NAME: AMETHYST GROVE ASSISTED LIVING
FACILITY NUMBER: 312700994

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/28/2023
Section Cited

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87465 Incidental Medical and Dental Care. (c)(2) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.
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Administrator agrees to send into CCL a copy of the training that was provided to staff after medication error occurred. Training to be sent into CCL by 2/28/23.
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Based on interviews conducted, the facility did not ensure residents are receiving medications as prescribed, which poses a health, safety, and personal rights risk to the 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: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2