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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005594
Report Date: 12/07/2021
Date Signed: 06/06/2022 12:43:30 PM

Document Has Been Signed on 06/06/2022 12:43 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:AMETHYST CARE HOME OF FULLERTONFACILITY NUMBER:
306005594
ADMINISTRATOR:MISA, MARIA THERESA CFACILITY TYPE:
740
ADDRESS:513 N CORNELL AVETELEPHONE:
(657) 217-5093
CITY:FULLERTONSTATE: CAZIP CODE:
92831
CAPACITY: 6CENSUS: 1DATE:
12/07/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:11 AM
MET WITH:Care staff George Agnote TIME COMPLETED:
12:25 PM
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Licensing Program Analyst (LPA) Shobhana Frank conducted an unannounced visit for the purpose of conducting a required annual visit.
LPA was greeted and granted entry into the facility by care staff George Agnote.

LPA Frank toured the facility. One resident residing in the facility and no active COVID-19 cases. All
resident and staff are vaccinated. LPA observed 1 resident on site and appeared clean and well
taken care of. LPA observed required department postings in the facility as well as hand washing signs in the
restrooms. All restrooms observed had ample soap/ sanitizer and appeared clean. Residents bedrooms
appeared clean and sanitary and had all required components. LPA Frank tested the hot water temperature,
which measured 108.8 degrees F in resident bathroom. Resident areas were noted to be a comfortable
temperature. LPA observed the emergency disaster and evacuation plans. Facility has back-up emergency
food and water supply as well as PPE supplies. Facility has completed the LIC 808 Mitigation Plan. The
facility is still conducting COVID-19 testing as required by the latest guidance.
No citations noted during today's visit. Exit interview conducted and a copy of this report was provided.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Shobhana Frank
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2021
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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