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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 315920013
Report Date: 03/07/2024
Date Signed: 03/07/2024 02:33:37 PM

Substantiated


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
01/09/2024 and conducted by Evaluator Melissa Parks
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20240109152358
FACILITY NAME:AMETHYST GROVE OF ROCKLINFACILITY NUMBER:
315920013
ADMINISTRATOR:ALLEN, MARCFACILITY TYPE:
740
ADDRESS:3908 RUTLAN WAYTELEPHONE:
(916) 772-1972
CITY:ROCKLINSTATE: CAZIP CODE:
95677
CAPACITY:6CENSUS: DATE:
03/07/2024
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Marc AllenTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility is not adequately staffed to meet the needs of the residents in care.
Staff did not allow a resident to utilize the call button.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Melissa Parks arrived unannounced on Thursday March 7th, 2024, to complete and deliver findings to a complaint received on 1/9/2024. LPA met with Administrator Marc and explained the purpose of the visit.

Throughout the course of the investigation, LPA interviewed the Administrator, staff, and R1’s hospice team. LPA reviewed R1’s file at the facility including physicians report, MARs, medication count sheet, and medication list. The result of the investigation is as follows:

LPA learned from interviews that the facility utilized staffing agencies to supplement caregivers when needed. During the last two weeks of December, one of the primary caregivers was out sick and the facility was not able to obtain coverage with the staffing agency. Per interviews, this left one caregiver to provide care and supervision for 6 residents which lead to delayed breakfast and care services. Additionally, interviews acknowledged that a staffing agency staff refused care for residents during NOC shift.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
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-20240109152358
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 OF ROCKLIN
FACILITY NUMBER: 315920013
VISIT DATE: 03/07/2024
NARRATIVE
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Based on the information detailed above, LPA finds the allegations to be substantiated. A finding that the allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiency cited on 9099-D. Appeal rights were printed and given.

Exit interview conducted. A copy of this report was left at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 59-AS-20240109152358
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 OF ROCKLIN
FACILITY NUMBER: 315920013
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/28/2024
Section Cited
CCR
87468.2
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Additional Personal Rights of Residents in Privately Operated Facilities
(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
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This requirement was not met as evidence by interviews acknowledging the facility was short of staff. Administrator to submit staffing plan in order to fill gaps in schedule due to staff illness, etc.
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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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
LIC9099 (FAS) - (06/04)
Page: 3 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
01/09/2024 and conducted by Evaluator Melissa Parks
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20240109152358

FACILITY NAME:AMETHYST GROVE OF ROCKLINFACILITY NUMBER:
315920013
ADMINISTRATOR:ALLEN, MARCFACILITY TYPE:
740
ADDRESS:3908 RUTLAN WAYTELEPHONE:
(916) 772-1972
CITY:ROCKLINSTATE: CAZIP CODE:
95677
CAPACITY:6CENSUS: DATE:
03/07/2024
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Marc AllenTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff over medicated a resident in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Melissa Parks arrived unannounced on Thursday March 7th, 2024, to complete and deliver findings to a complaint received on 1/9/2024. LPA met with Administrator Marc and explained the purpose of the visit.

Throughout the course of the investigation, LPA interviewed the Administrator, staff, and R1’s hospice team. LPA reviewed R1’s file at the facility including physicians report, MARs, medication count sheet, and medication list. The result of the investigation is as follows:

LPA reviewed R1’s medication list and verified that the medications were listed and being given according to the MAR. According to the medication count sheet, R1 was given one dose of PRN Lorazepam .5 mg on 12/3/2023, 12/4/2023, and 12/5/2023. According to the Clinical Director of R1’s hospice agency, this was the appropriate dosage based on R1’s symptoms. They stated that the life span of this drug is approximately six hours and therefore could not affected the resident for days after it was taken. The clinical director stated that the facility was appropriately given the medication.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 59-AS-20240109152358
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 OF ROCKLIN
FACILITY NUMBER: 315920013
VISIT DATE: 03/07/2024
NARRATIVE
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Based on the evidence provided, the preponderance of evidence standards was not met, therefore, the above allegation is found to be UNFOUNDED. An unfounded allegation means that the allegation was false, could not have happened and/or is without a reasonable basis.

Exit interview conducted. A copy of this report was left at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5