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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 045002441
Report Date: 09/16/2026
Date Signed: 09/16/2026 03:29:20 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
11/24/2025 and conducted by Evaluator Kayla Adkison
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20251124111505
FACILITY NAME:AMBER GROVE PLACEFACILITY NUMBER:
045002441
ADMINISTRATOR:REITZ, BRENDAFACILITY TYPE:
740
ADDRESS:3049 ESPLANADETELEPHONE:
(530) 826-3226
CITY:CHICOSTATE: CAZIP CODE:
95973
CAPACITY:70CENSUS: 50DATE:
09/16/2026
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Stacey Baxter, AdministratorTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff did not follow resident's care plan
Staff did not ensure resident's room was clean
Staff did not ensure resident's wheelchair was clean
INVESTIGATION FINDINGS:
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On September 9, 2026, Licensing Program Analyst (LPA) Kayla Adkison arrived at the facility unannounced for the purpose pf delivering complaint findings. LPA was greeted by Administrator, Stacey Baxter, and explained the purpose of the visit. During the visit, there were 50 residents and 10 staff providing direct care.

During the course of the investigation, interviews were conducted, observations were made, and pertinent records were reviewed.

Continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Kayla Adkison
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2026
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 8
Control Number 59-AS-20251124111505
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: AMBER GROVE PLACE
FACILITY NUMBER: 045002441
VISIT DATE: 09/16/2026
NARRATIVE
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Allegation: Staff did not follow resident's care plan

It was alleged that staff did not follow a resident’s (R1) care plan throughout their residency at the facility. Specifically, it was alleged that staff were not properly assisting the resident with bathing or daily grooming, not setting R1’s wheelchair up properly during meals resulting in food waste messes, and the facility donated a sit-to-stand device that the resident had a medical order to use. LPA reviewed all of R1’s care plans and confirmed these services/interventions were all documented as activities of daily living that staff were required to assist R1 with on a daily basis.

LPA interviewed staff members during the course of the investigation. Staff #1 (S1) noted that the above allegation “may have been true in previous years” as S1 remembered R1’s family complaining about their level of care “many times.” S1 further stated that staff were directed to “shave R1 more often” indicating this task was not being completed daily. LPA reviewed R1’s initial care plan from their move which indicated “staff to provide daily shaving. Resident may refuse. Repeat attempts.” Additionally, LPA reviewed the R1’s shower logs and noted that no shower was given between July 22, 2025, and August 5, 2025, indicating 13 days passed without R1 receiving a shower. LPA reviewed R1’s progress notes for this period and found no documentation of R1’s refusal of shower during this period. All R1’s care plans created by facility staff throughout R1’s residency at the facility indicated R1 was to receive showers twice a week.

LPA reviewed photographs documenting incidents when the resident’s wheelchair foot guard and seat area were covered in food waste, indicating the resident was not properly assisted during mealtime and his care plan order for a “plate guard” was not being followed.

LPA interviewed staff regarding the previously mentioned use of the sit-to-stand “hoyer” device. Staff #2 (S2) stated the device was donated to the facility by a previous resident’s family. In order for R1 to use the device, it needed to be evaluated by a physical therapist and approved for R1s use. The evaluation was facilitated and it was determined that R1 was not compatible with the device due to R1’s lack of compliance with its utilization. It was determined in the evaluation and documented in R1’s care plan dated September 21, 2025, that “if the time comes where (R1) becomes unable to assist with transfers, the sit to stand will be re-introduced and another training will be held with the PT (physical therapist) for staff training.” S2 confirmed the device was subsequently donated to a local non-profit organization without notifying R1’s responsible party (RP).

Based on interviews conducted, observations, and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Kayla Adkison
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 59-AS-20251124111505
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: AMBER GROVE PLACE
FACILITY NUMBER: 045002441
VISIT DATE: 09/16/2026
NARRATIVE
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Allegation: Staff did not ensure resident's room was clean

It was alleged that staff did not ensure that the resident’s room was kept clean and sanitary in that there were several instances where feces remnants were left on surfaces throughout the resident’s bathroom following showers and toileting assistance.

Photographs dated August 5, 2025, were reviewed and showed feces on the resident’s shower floor and shower chair. LPA reviewed facility housekeeping logs, shower logs, and R1’s progress notes. Prior to August 5, 2025, the resident’s last recorded shower was provided on July 22, 2025, 13 days earlier, indicating that would have been the latest point in time when the soiling of the resident’s shower chair occurred. According to housekeeping logs, the resident’s room was serviced July 27, 2025. On a Housekeeping Report dated the same day, it was documented that housekeeping staff “changed bedding, cleaned the bedroom and bathroom,” however, the soilage remained until the photograph was taken on August 5, 2025. According to R1’s 2025 care plan, R1 was to be provided with a two-person assist with each shower, twice a week. Thus, indicating two staff members should have been present on July 27, 2025, for the resident’s last known shower. These two (2) staff members would have observed the soiling of the shower floor and shower chair and chose to neither clean the mess themselves, or alert housekeeping staff to the need for additional disinfecting of R1’s bathroom.

Photographs dated August 25, 2025, were reviewed and showed feces remnants on R1’s bathroom floor, toilet seat, and inside the trashcan. Housekeeping reports indicated R1’s room was last serviced on August 19, 2025, where the notes indicate “cleaned room, bathroom”, thus indicating the soiling of the bathroom services occurred between August 19, 2025, and August 25, 2025. According to R1’s 2025 care plan, the resident required a two-person transfer for toileting indicating two staff would have present in the resident’s room multiple times within the above-mentioned time period and observed the mess without cleaning or alerting housekeeping.

Continued on additional LIC 9099-C
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Kayla Adkison
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 59-AS-20251124111505
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: AMBER GROVE PLACE
FACILITY NUMBER: 045002441
VISIT DATE: 09/16/2026
NARRATIVE
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Finally, a photograph dated September 19, 2025, showed feces remnants on R1’s shower chair. It was alleged that the soiling was left there by staff for three days and the resident’s responsible party cleaned it themselves. Shower logs indicated R1 received a shower September 16, 2025, and September 19, 2025. Two staff should have been present for both showers and observed the soilage. LPA was provided housekeeping logs dated September 2, 2025, and September 30, 2025, indicating R1’s room was serviced. There was no documentation provided to the LPA indicating the resident’s room had been serviced between those dates.

Based on interviews conducted, observations, and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D.

Allegation: Staff did not ensure resident's wheelchair was clean

It was alleged that staff did not clean the resident’s wheelchair, particularly following meals.
LPA observed photo documentation dated August 15, 2025, of food soilage covering the foot plate of the resident’s wheelchair. R1’s family reportedly cleaned the wheelchair.

LPA reviewed the resident’s 2025 care plan which indicated the resident was to be provided a plate guard which would assist the resident in keeping food from falling to the resident’s feet. Due to the food soilage observed on the resident’s footplate, it is deducted that the care plan was not followed.
Additionally, on August 13, 2025, a note was written in the care plan indicating that R1 would now require 1-on-1 assistance with feeding by a staff member. Specifically, the services/interventions column of the care plan indicates “Staff will provide set up, plating, and serving all meals/fluids.” If staff were providing the resident with the service documented in the care plan, staff would have observed the food mess created on the resident’s wheelchair and should have aided with cleaning in order to provide R1 with clean, healthful, accommodations.

Based on interviews conducted, observations, and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D. Exit interview conducted. A copy of this report and Appeal Rights were provided to Administrator, Stacey Baxter
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Kayla Adkison
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 59-AS-20251124111505
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: AMBER GROVE PLACE
FACILITY NUMBER: 045002441
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/02/2026
Section Cited
HSC
1569.2(c)
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Health and Safety Code section 1569.2(c) provides: (c) "Care and supervision" means the facility assumes responsibility for, or provides… ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with taking medications, money management, or personal care. This requirement was not met as evidenced by:
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POC: Licensee/Administrator shall conduct a staff training regarding the above-mentioned regulation and the importance of following resident care plans. Administrator shall submit training outline/agenda and staff sign in sheet to LPA by end of business on October 3, 2026.
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Based on interviews conducted and records reviewed, it was determined that staff did not ensure that R1’s care plan was being followed in that staff were not assisting the resident with regular grooming/bathing, staff were not providing the resident with his plate guard during meals, and staff donated a sit to stand device of which the resident had a medical order to utilize at a future date. This poses a potential health, safety, and/or personal rights risk to residents in care.
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Type B
10/02/2026
Section Cited
CCR
87303(A)(1)
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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.
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POC: Licensee/Administrator shall conduct a training, to include housekeeping staff, on ensuring resident’s rooms and personal areas are kept clean and sanitary at all times. Administrator shall submit training outline/agenda and staff sign in sheet to LPA by end of business on September 25, 2026.
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Based on interviews conducted, LPA observations, and records reviewed, it was determined that staff did not ensure that the facility was clean, safe, sanitary, and in good repair at all times, in that R1’s bathroom was found to have feces remnants on several occasions where staff did not take action or alert housekeeping to the need for extra services. This poses a potential health, safety, and/or personal rights risk to 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: Lauren Crocker
LICENSING EVALUATOR NAME: Kayla Adkison
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 59-AS-20251124111505
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: AMBER GROVE PLACE
FACILITY NUMBER: 045002441
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/02/2026
Section Cited
CCR
87468.1(a)
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87468.1 Personal Rights of Residents in All Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
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POC: Licensee/Administrator shall conduct a training, to include housekeeping staff, on ensuring resident’s rooms and personal effects (i.e. wheelchairs, walkers, etc.) are kept clean and sanitary at all times. Administrator shall submit training outline/agenda and staff sign in sheet to LPA by end of business on October 3, 2026.
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Based on interviews conducted, LPA observations, and records reviewed, it was determined that staff did not accord R1 with healthful and comfortable accommodations in that staff failed to clean food waste from R1s wheelchair footplate following meals. This poses a potential health and safety risk to 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: Lauren Crocker
LICENSING EVALUATOR NAME: Kayla Adkison
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 8
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
11/24/2025 and conducted by Evaluator Kayla Adkison
COMPLAINT CONTROL NUMBER: 59-AS-20251124111505

FACILITY NAME:AMBER GROVE PLACEFACILITY NUMBER:
045002441
ADMINISTRATOR:REITZ, BRENDAFACILITY TYPE:
740
ADDRESS:3049 ESPLANADETELEPHONE:
(530) 826-3226
CITY:CHICOSTATE:CAZIP CODE:
95973
CAPACITY:70CENSUS: 50DATE:
09/16/2026
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Stacey Baxter, AdministratorTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff did not notify authorized representative of change of condition in resident
INVESTIGATION FINDINGS:
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On September 9, 2026, Licensing Program Analyst (LPA) Kayla Adkison arrived at the facility unannounced for the purpose pf delivering complaint findings. LPA was greeted by Administrator, Stacey Baxter, and explained the purpose of the visit. During the visit, there were 50 residents and 10 staff providing direct care.

During the course of the investigation, interviews were conducted, observations were made, and pertinent records were reviewed.

Continued on LIC 9099-C
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Kayla Adkison
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 59-AS-20251124111505
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: AMBER GROVE PLACE
FACILITY NUMBER: 045002441
VISIT DATE: 09/16/2026
NARRATIVE
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Allegation: Staff did not notify authorized representative of change of condition in resident

It was alleged that R1 experienced a change in condition and the resident’s responsible party was not informed. Upon further investigation and interview, it was determined this allegation was a misunderstanding of the circumstances of the complaint and was ultimately determined to be a clerical error.

This allegation is unfounded. A finding that the allegation is unfounded means the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview conducted. A copy of this report was provided to Administrator, Stacey Baxter.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Kayla Adkison
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2026
LIC9099 (FAS) - (06/04)
Page: 8 of 8