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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005975
Report Date: 08/12/2021
Date Signed: 08/12/2021 03:19:11 PM

Document Has Been Signed on 08/12/2021 03:19 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 HOMEFACILITY NUMBER:
306005975
ADMINISTRATOR:SANGRADOR, MARIA CECILIAFACILITY TYPE:
740
ADDRESS:10542 SHERRILL ST.TELEPHONE:
(657) 347-9605
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 6CENSUS: 3DATE:
08/12/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:46 PM
MET WITH:Maria Cecilia SangradorTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Lydia Martinez conducted an unannounced visit for the purpose of conducting a Required - 1 Year evaluation on facility Amethyst Home #2. LPA was greeted and granted entry into the facility by Administrator Maria Cecilia Sangrador who told LPA that Amethyst Home #2 was no longer in business. LPA conducted a Case Management visit on above facility. Administrator Manuel Abadines arrived shortly after.

LPA did not observe required COVID-19 precautionary postings at the front entrance or none were observed during walk through of the facility. LPA did observe a sign in sheet, and sanitization station. Administrator stated temperature is taken but not logged. LPA provided facility staff with required postings which Administrator posted during the visit.

LPA consulted with Administrators on the importance of infection control, temperature log, and screening residents and logging temperature.

LPA consulted with Administrators regarding the importance of following up on tPINS.

LPA Martinez obtained a copy of facilities Mitigation Plan.

No deficiencies noted during today's visit. An exit interview was conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 08/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2021
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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