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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700994
Report Date: 05/03/2023
Date Signed: 05/03/2023 01:26:00 PM


Document Has Been Signed on 05/03/2023 01:26 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
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



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: 4DATE:
05/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Nayely Gilbert, House ManagerTIME COMPLETED:
01:40 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 and administrator Marc Allen during today's inspection.

LPA toured facility with administrator to ensure health and safety of residents in care. LPA toured 6 resident rooms, 3 bathrooms, kitchen, common living spaces, backyard and the garage area. In the areas toured no immediate health, safety, or personal rights violations were observed. Administrator stated there has been no positive COVID cases at the facility, and sufficient amount of PPE. LPA toured the backyard and all exits are accessible and unlocked. There is a locked storage for medications and toxins. Food supply is adequate for 2-day perishable and 7-day nonperishable. LPA observed an adequate amount of linens and found the first aid kit to be complete.

LPA reviewed 2 of 4 resident files and 2 staff files. LPA reviewed medications of two residents comparing with Centrally Stored Medication Record and physician orders. A review of staff records indicates that all facility staff has received criminal record clearances and/or are associated to this facility. Staff records reviewed indicated current first aid certificates and training completed. LPA observed a copy of current liability insurance.

LPA observed R1 did not have a physician order for 2 over the counter medications and R2 had 3 expired medications in their medication box.

Exit interview conducted and appeal rights provided.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/03/2023 01:26 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
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833


FACILITY NAME: AMETHYST GROVE ASSISTED LIVING
FACILITY NUMBER: 312700994

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
87465 Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 2 out of 2 persons, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2023
Plan of Correction
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Administrator agrees to conduct a medication audit for all residents in care. In addition, Adminsitrator to provide a training to all staff on medication dispensing and documentation. Training documents and sign in sheet of who attended training to be sent into CCL by 5/12/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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) 204-8288
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2023
LIC809 (FAS) - (06/04)
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