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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315920013
Report Date: 07/11/2023
Date Signed: 07/11/2023 01:26:44 PM


Document Has Been Signed on 07/11/2023 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:AMETHYST GROVE OF ROCKLINFACILITY NUMBER:
315920013
ADMINISTRATOR:ALLEN, MARCFACILITY TYPE:
740
ADDRESS:3908 RUTLAN WAYTELEPHONE:
(916) 250-1128
CITY:ROCKLINSTATE: CAZIP CODE:
95677
CAPACITY:6CENSUS: 3DATE:
07/11/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Nayely Gilbert, House Manager and Marc Allen, Administrator TIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a pre-licensing inspection for a change in ownership. LPA met with Nayely Gilbert, House Manager, and explained purpose of inspection. Also present was caregiver, Joan Freckleton-Jones. Marc Allen, Administrator, arrived at approximately 11:30 am. LPA observed (3) residents present and was advised (2) residents are currently under hospice care.

LPA and House Manager toured the interior and exterior of the facility including the common areas, (6) private resident bedrooms, (4) resident bathrooms with showers, kitchen, office, locked laundry and medication area and garage. There is a staff living area on the second floor.

LPA observed the facility to be clean, in good repair and to have sufficient furniture and lighting and the bathrooms to have the necessary grab bars, non-skid flooring, and hand-washing posters. LPA observed sufficient 2+day perishable and 7+day non-perishable supply of food in the kitchen and sharps and toxins to be locked using magnetic locks. LPA observed locked medications and additional locked toxins in the laundry area. LPA observed a covered patio table and chairs and (2) unlocked exit gates in the backyard. LPA observed the inside temperature to be 74*F. Fire extinguisher was last serviced on 4/24/2023 and all doors to have alarms. LPA observed a complete First Aid kit, PPE and paper supplies. All smoke/monoxide alarms were recently tested by the fire department and were functioning. Water temperature is set at 115*F per water heater reading. LPA observed sufficient linens/towels. LPA observed various required postings posted- Administrator to post Theft & Loss Policy, blank admission agreement and visitation policy. (2) resident binders and (1) staff files was reviewed and found to contain current documentation. All staff are fingerprint cleared.
Component III was reviewed during today’s inspection. Pre-Licensing is complete and this facility has no deficiencies.
Exit interview. Copy of report provided to Administrator. LPA to notify to the Centralized Applications Bureau.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2023
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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