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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005594
Report Date: 10/28/2024
Date Signed: 10/28/2024 11:25:30 AM

Document Has Been Signed on 10/28/2024 11:25 AM - 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/
DIRECTOR:		MISA, MARIA THERESA CFACILITY TYPE:
740
ADDRESS:513 N CORNELL AVETELEPHONE:
(714) 213-8411
CITY:FULLERTONSTATE: CAZIP CODE:
92831
CAPACITY: 6CENSUS: 6DATE:
10/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:40 AM
MET WITH:Flordeliza Villena, Charesa ReyesTIME VISIT/
INSPECTION COMPLETED:
11:40 AM
NARRATIVE
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Staff #1 (S1) Flordeliza Villena and discussed the purpose of the inspection. Administrator (AD) Charesa Reyes arrived during the inspection.

LPA reviewed Infection Control requirements. At about 8:15AM, LPA and S1 conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and garage and observed the following: Structure: facility is a 4-bedroom, 2-bathroom, one-story house with detached garage that is used for storage. There is a back yard with a patio cover for the residents. LPA observed 2 staff and 6 residents present at the facility. Resident Bedrooms: the 3 resident bedrooms are spacious and will easily accommodate the residents’ furnishings. Furniture for each resident bedroom inspected. Staff Bedrooms: LPA inspected the one staff bedroom. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested at 107 degrees F in the common resident bathroom and 106 degrees in the private resident bathroom. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed and tested. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the kitchen and garage. Medication cabinet: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. Facility’s licensing fees are paid. At about 9:15AM, LPA reviewed 6 resident files and 3 staff files, interviewed 6 residents and 2 staff, and inspected medications for 6 residents. Facility does not handle resident money.

CONTINUED
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
Document Has Been Signed on 10/28/2024 11:25 AM - It Cannot Be Edited


Created By: Sean Haddad On 10/28/2024 at 11:03 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: AMETHYST CARE HOME OF FULLERTON
FACILITY NUMBER: 306005594

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on documents, admission, and confirmation from the licensee's insurance agent, the licensee's liability insurance expired on January 14, 2024, and has not been renewed, which poses an immediate personal rights risk to persons in care.
POC Due Date: 10/29/2024
Plan of Correction
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Licensee stated they will obtain liability insurance immediately and submit proof to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Armando J Lucero
LICENSING EVALUATOR NAME:Sean Haddad
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/28/2024 11:25 AM - It Cannot Be Edited


Created By: Sean Haddad On 10/28/2024 at 11:03 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: AMETHYST CARE HOME OF FULLERTON
FACILITY NUMBER: 306005594

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87205(b)
Accountability of Licensee Governing Body
(b) If the licensee is a corporation or an association, the governing body shall be active, and functioning in order to assure accountability.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on California Secretary of State documents, the licensee corporation is suspended, which poses a potential safety risk to persons in care.
POC Due Date: 11/25/2024
Plan of Correction
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Licensee stated they will begin the Rivivor process and submit proof to LPA by POC due date.
Type B
Section Cited
HSC
1569.69(a)(2)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on documents, the licensee did not ensure S1 and S2 completed the 10 hour medication training (6 hours hands-on, 4 hours other training/instruction) prior to assisting with medications, which poses a potential health risk to persons in care.
POC Due Date: 11/25/2024
Plan of Correction
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Licensee stated they will finish the medication training and submit proof to LPA by POC due date.
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:Armando J Lucero
LICENSING EVALUATOR NAME:Sean Haddad
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 FULLERTON
FACILITY NUMBER: 306005594
VISIT DATE: 10/28/2024
NARRATIVE
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During the inspection, LPA and AD observed the following: based on California Secretary of State documents, the licensee corporation is suspended; based on documents, admission, and confirmation from the licensee's insurance agent, the licensee's liability insurance expired on January 14, 2024, and has not been renewed; and based on documents, the licensee did not ensure S1 and S2 completed the 10 hour medication training (6 hours hands-on, 4 hours other training/instruction) prior to assisting with medications.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024
LIC809 (FAS) - (06/04)
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