315920013-8-1-2024-59-AS-MSEY-D7RT66-20240802142635

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 315920013
Report Date: 08/01/2024
Date Signed: 08/01/2024 02:09:01 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
06/18/2024 and conducted by Evaluator Melissa Parks

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20240618122446

FACILITY NAME:	AMETHYST GROVE OF ROCKLIN		FACILITY NUMBER:	315920013
ADMINISTRATOR:	ALLEN, MARC		FACILITY TYPE:	740
ADDRESS:	3908 RUTLAN WAY		TELEPHONE:	(916) 772-1972
CITY:	ROCKLIN	STATE: CA	ZIP CODE:	95677
CAPACITY:	6	CENSUS: 2	DATE:	08/01/2024
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Marc Allen		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff are retaining a resident that requires a higher level of care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Melissa Parks arrived unannounced on Thursday August 1, 2024 to complete and deliver findings to a complaint received on 6/18/2024. LPA met with Administrator Marc and explained the purpose of the visit.

Throughout the course of the investigation, LPA interviewed the Administrator, staff, and R2. LPA reviewed R1’s medication list, physicians report, care plan, and incident reports. The result of the investigation is as follows:

LPA interviewed staff who stated that R1 had episodes of aggression towards staff and residents. Staff stated that, at times, they were unable to redirect R1. R1 has had episodes of kicking, biting, and hitting staff. Additionally, R1 has attempted to attack other residents at the facility. LPA reviewed an incident report dated 5/15/2024 which details how R1 charged at R2. Staff intervened and R1 began to hit them. LPA reviewed an incident report dated 5/9/2024 which stated that R1 punched staff resulting in a black eye. Staff stated that R1 has a 1:1 for 6 hours a day, three times per week.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa Parks	TELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20240618122446

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: 08/01/2024

NARRATIVE

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However, staff stated that they are unable to manage R1’s behaviors when there is not a 1:1 present.
Based on the information detailed above, LPA finds the allegation 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 given.

Exit interview conducted. A copy of this report was left at the facility.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa Parks	TELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20240618122446

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: 08/01/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/02/2024 Section Cited ILS 1569.312(e)	1 2 3 4 5 6 7	Basic services requirements Every facility required to be licensed under this chapter shall provide at least the following basic services: (e) Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being	1 2 3 4 5 6 7	Administrator agrees to submit a plan to follow regarding residents requiring higher level of care
	8 9 10 11 12 13 14	This requirement was not met as acting physically aggressive with staff and residents. This poses a direct threat to the health and safety of residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa Parks	TELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024

LIC9099 (FAS) - (06/04)

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