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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005975
Report Date: 05/04/2021
Date Signed: 05/04/2021 10:20:13 AM

Document Has Been Signed on 05/04/2021 10:20 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, 744 P STREET, MS 8-3-91
SACRAMENTO, CA 95814
FACILITY NAME:AMETHYST HOMEFACILITY NUMBER:
306005975
ADMINISTRATOR:SANGRADOR, MARIA CECILIAFACILITY TYPE:
740
ADDRESS:10542 SHERRILL ST.TELEPHONE:
(657) 256-1620
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 6CENSUS: DATE:
05/04/2021
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Manuel Abadines and Maria SangradorTIME COMPLETED:
10:10 AM
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Facility Type: RCFE Application Type: CHOW Capacity: 6 Census (if any clients in care): 2
COMP II Participants: Manuel Abadines, Corporate Board Member, and Maria Sangrador, Administrator and Corporate Board Member
Interview Method: Telephone interview
On 5/04/2021, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained. Applicant has also been sent a copy of PIN 20-48-ASC. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISORS NAME: Julia Kim
LICENSING EVALUATOR NAME: Bailey Humes
LICENSING EVALUATOR SIGNATURE: DATE: 05/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/04/2021
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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