<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005975
Report Date: 07/29/2025
Date Signed: 07/29/2025 09:05:30 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/11/2025 and conducted by Evaluator Andrea Mendivil
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250211155116
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: 6DATE:
07/29/2025
UNANNOUNCEDTIME BEGAN:
07:33 AM
MET WITH:Manuel Abadines- Administrator and Maria Sangrador - Licensee/Administrator TIME COMPLETED:
09:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff did not prevent resident from sustaining multiple burns
Facility staff did not seek timely medical attention for resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the facility and explained the reason for the visit.

The Department received a complaint on February 11, 2025, and LPA Ruppert conducted the initial 10 day visit. LPA Ruppert collected documents including Identification and Emergency Forms, Appraisal Needs & Services Plans, Physician’s Reports and Admissions Agreements. Regarding the allegations, facility staff did not seek timely medical attention for resident and facility staff did not prevent resident from sustaining multiple burns, the investigation revealed the following:

On January 21, 2025, around 2:00pm Resident 1 (R1) asked Caregiver 1 (C1) for a cup of coffee. It was reported by C1 that they put the water for instant coffee in the microwave and provided R1 with the hot coffee on a side table.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 22-AS-20250211155116
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 HOME
FACILITY NUMBER: 306005975
VISIT DATE: 07/29/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
C1 advised R1 to be careful due to the coffee being hot. C1 stepped away from the living room and went back to work in the kitchen. A few minutes later C1 heard R1 shout. C1 then went to R1 and R1 had spilled coffee on their left arm, left thigh and stomach. It was reported that R1 had fallen asleep with the coffee cup in their hands after not being able to sleep for four nights. C1 then took R1 to the sink to apply cold running water to their left arm and then cold damp cloth to R1’s thigh and stomach. C1 then notified Administrator Maria Sangrador who assessed R1 and observed a small blister on the left arm. Administrator stated she felt she could tend to the wounds as she is a nurse.

In the week following, R1 had reported not feeling well and asked to be taken to the hospital. R1 was finally taken to the hospital on January 25, 2025, four days after the incident, due to being lethargic and non-responsive. R1 went into respiratory failure and was intubated while at the hospital. R1 was diagnosed with 2nd degree burns and pneumonia.

Therefore, based on the preponderance of evidence through records reviewed and interviews the allegations facility staff did not seek timely medical attention for resident and facility staff did not prevent resident from sustaining multiple burns are determined to be SUBSTANTIATED meaning the complaint allegation is valid and that a violation has occurred.

See LIC9099-D for cited deficiencies and immediate civil penalty as per Title 22 Division 6 of the California Code of Regulations.

A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49 (f)

An exit interview was conducted Administrator. A copy of this report, along with LIC9099-D, Appeal Rights, Civil Penalty Assessment-LIC 421 IM and the LIC 811, identifying confidential names were provided and explained.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 22-AS-20250211155116
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 HOME
FACILITY NUMBER: 306005975
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/30/2025
Section Cited
CCR
87464(f)(1)
1
2
3
4
5
6
7
Basic services shall at a minimum include: Care and supervision defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).
1
2
3
4
5
6
7
Licensee purchased lids for all mugs and cups to ensure that are spill proof. Licensee to also conduct in service regarding hot beverage items.
Immediate Civil Penalty assessed
8
9
10
11
12
13
14
 This requirement was not met as evidence by Licensee did not ensure resident was supervised while drinking hot coffee. This poses an immediate health and safety risk to persons in care.
8
9
10
11
12
13
14
Type A
07/30/2025
Section Cited
CCR
87465(g)
1
2
3
4
5
6
7
Incidental Medical and Dental Care. The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health…
1
2
3
4
5
6
7
Licensee to conduct inservice regarding when to seek medical care.
8
9
10
11
12
13
14
This requirement is not met as evidence by Licensee did not seek timely medical when Resident 1 (R1) stated they did not feel well after hot coffee burns to the left arm, left thigh and stomach area. This poses an immediate health and safety risk to persons in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/11/2025 and conducted by Evaluator Andrea Mendivil
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250211155116

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: DATE:
07/29/2025
UNANNOUNCEDTIME BEGAN:
07:33 AM
MET WITH:TIME COMPLETED:
09:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff are not ensuring residents medical equipment is properly utilized
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the facility and explained the reason for the visit.

The Department received a complaint on 02/11/2025 and LPA Ruppert conducted the initial 10 day visit. LPA Ruppert collected pertinent documents such as Identification and Emergency Forms, Appraisal Needs & Services Plans, Physician’s Reports and Admissions Agreements. Regarding the allegation facility staff are not ensuring residents medical equipment is properly utilized, the investigation revealed the following:

It was alleged that Resident 1 (R1) was not utilizing their medical equipment. Per review of R1’s Kaiser After Visit Summary dated 01/20/2025 listed the diagnosis of obstructive sleep apnea. Based on interviews with Administrator Manuel Abadines stated that after the visit on 01/20/2025 R1 was given a Bipap machine to assist with sleep apnea.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20250211155116
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 HOME
FACILITY NUMBER: 306005975
VISIT DATE: 07/29/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Administrator Manuel stated that R1 would not want to wear the machine due to feeling anxious when their face was covered. Interviews with 2 out of 2 staff indicated that the machine was available and working. Administrator stated took the bipap machine to Apria Healthcare in Irvine, CA in May 2025 and technician stated that the machine is working properly. Administrator stated asked company if R1 could get a smaller mask but was told due to fit the larger mask was a better fit for R1. Administrator stated that R1 would use the machine for 10 -15 mins and then switch to oxygen as that made R1 more comfortable.

Therefore based on the preponderance of evidence through records reviewed and interviews the allegation facility staff are not ensuring residents medical equipment is properly utilized is determined to be UNSUBSTANTIATED, meaning although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5