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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006384
Report Date: 03/28/2024
Date Signed: 03/28/2024 03:58:13 PM

Document Has Been Signed on 03/28/2024 03:58 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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:AMETHYST HOME 2FACILITY NUMBER:
306006384
ADMINISTRATOR:ABADINES, MANUELFACILITY TYPE:
740
ADDRESS:6022 AMBERDALE DRTELEPHONE:
(657) 347-9605
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY: 6CENSUS: 0DATE:
03/28/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Manuel Abadines, Maria Cecilia-Sangrador AdministratorsTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. made an announced inspection to the facility for purpose of conducting a pre-licensing inspection. LPA arrived and was greeted and granted entry by Administrators Manuel Abadines and Maria Cecilia-Sangrador. An application to operate a Residential Care Facility for the Elderly (RCFE) for (6) capacity, (0) ambulatory, (6) non-ambulatory, and (0) bedridden residents was received by Community Care Licensing (CCL) on 7/20/2023.

The facility is a one-story home with three shared resident bedrooms, two bathrooms, two living rooms, dining room, kitchen, staff lounge, laundry room and backyard.

Client Bedrooms have all the necessary requirements including bed, chair, storage for clothing and ample lighting. LPA observed all windows were screened.

All bathrooms have working plumbing and designated hand washing posters. Hot water measured between 119 and 120 degrees Fahrenheit. LPA issued a technical assistance advising the ADs to maintain a water log to ensure proper temperatures continue to be maintained.

LPA observed the fire extinguisher to be fully charged as indicated by the arrow pointing in the green zone. The service tag indicates the extinguisher was serviced on May 2, 2023.

Medications and First-Aid Kit will be locked in a lock box in a closet in the hallway. Resident & Staff Files will be locked in a closet in the living room.

The fire clearance was approved by a fire inspector of Orange County Fire Authority on 7/31/2023.

Extra hygiene supplies and linens will be stored in a closet in the hallway.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2024
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: AMETHYST HOME 2
FACILITY NUMBER: 306006384
VISIT DATE: 03/28/2024
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LPA observed space in the garage where the ADs will keep chemicals, cleaning solutions, laundry toxins and disinfectants. ADs stated they will purchase additional locks to ensure all toxins remain inaccessible to residents.

Emergency Phone Numbers, Exit Plan, Activity Calendar and Menu are all posted and available for review. LPA observed other necessary postings in the living room.

Smoke and Carbon Monoxide detectors are stationed throughout the home and are wired together. Both types of detectors were tested and noted as operational.

Operational appliances include a gas stove, oven, two refrigerators, dishwasher, microwave, washing machine and dryer.

LPA reviewed and provided Administrators with the Component III presentation to offer information and resources regarding maintaining facility compliance.

The designated ADs was notified that the final application approval will be issued by the Centralized
Applications Bureau in Sacramento. Exit interview was conducted and a copy of this report was provided to
designated AD.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024
LIC809 (FAS) - (06/04)
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