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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005594
Report Date: 09/15/2022
Date Signed: 09/15/2022 01:53:39 PM


Document Has Been Signed on 09/15/2022 01:53 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:MISA, MARIA THERESA CFACILITY TYPE:
740
ADDRESS:513 N CORNELL AVETELEPHONE:
(657) 217-5093
CITY:FULLERTONSTATE: CAZIP CODE:
92831
CAPACITY:6CENSUS: 6DATE:
09/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Grace Rogong, Editha BelenTIME COMPLETED:
02:00 PM
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting an Annual Inspection. LPA met with staff Grace Rogong and Editha Belen and discussed the purpose of the inspection. During the inspection, LPA and staff conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and garage and observed the following:

During the inspection, LPA observed there were 3 staff present, wearing PPE. LPA observed 6 residents were present. LPA confirmed the residents were doing well and observed no health and safety issues. LPA inspected common areas, resident rooms, kitchen, and garage and observed they were clean and organized, and found no health and safety issues. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. LPA observed hallways and walkways were free of obstruction.

LPA reviewed and confirmed facility policies and practices regarding resident screening, staff screening, visitation, COVID-19 surveillance testing, COVID-19 clearance testing, quarantine, isolation, cohorting, staffing, infection control/lead/training, PPE, staffing and staffing shortages, communication and emergency plan, and dementia. LPA requested and reviewed resident roster, staff roster, staff files, resident files, emergency plan, COVID-19 mitigation plan, and Infection Control Plan. LPA provided technical assistance regarding N95 Fit Testing, Guardian, facility records, and bedrails.

There were no health and safety concerns observed in the areas inspected. Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2022
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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