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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005594
Report Date: 12/04/2024
Date Signed: 12/04/2024 04:06:06 PM

Document Has Been Signed on 12/04/2024 04:06 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/
DIRECTOR:		MISA, MARIA THERESA CFACILITY TYPE:
740
ADDRESS:513 N CORNELL AVETELEPHONE:
(714) 213-8411
CITY:FULLERTONSTATE: CAZIP CODE:
92831
CAPACITY: 6CENSUS: 6DATE:
12/04/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:18 PM
MET WITH:Flordeliza VillenaTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
NARRATIVE
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This unannounced POC inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of verifying correction of deficiencies issued during the Required – 1 Year Inspection conducted on October 28, 2024. LPA met with Staff #1 (S1) Flordeliza Villena and discussed the purpose of the inspection. Administrator (AD) Charesa Reyes appeared via telephone.

During the inspection, LPA and S1 toured the facility and observed the following:

Type A Violation cited under Health & Safety Code Section 1569.605 pertaining to liability insurance has not been cleared. During today’s inspection, AD was not able to provide proof of liability of insurance. Civil penalties for repeat violations are being assessed.

Type B Violation cited under California Code of Regulations (CCR) Title 22, Section 87205(b) pertaining to the licensee corporation being suspended has not been cleared. During today’s inspection, LPA reviewed California Secretary of State documents showing that the licensee corporation is still suspended and AD has not submitted any proof that the Revivor process has been initiated. Civil penalties for failure to correct are being assessed.

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. Civil penalties for repeat violations and failure to correct are being assessed. See LIC421FC. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2024
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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Document Has Been Signed on 12/04/2024 04:06 PM - It Cannot Be Edited


Created By: Sean Haddad On 12/04/2024 at 03:45 PM
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: 12/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/05/2024
Section Cited
HSC
1569.605

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... all residential care facilities for the elderly... shall maintain liability insurance ...
This requirement is not met as evidenced by:
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CIVIL PENALTY ASSESSED. Licensee stated they will obtain liability insurance immediately and submit proof to LPA by POC due date.
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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.
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Type B
01/01/2025
Section Cited
CCR87205(b)

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(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:
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Licensee stated they will begin the Rivivor process and submit proof to LPA by POC due date.
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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. CIVIL PENALTY ASSESSED.
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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: 12/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2024


LIC809 (FAS) - (06/04)
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