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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005975
Report Date: 05/31/2022
Date Signed: 05/31/2022 02:34:59 PM


Document Has Been Signed on 05/31/2022 02:34 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: 4DATE:
05/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Manuel Abadines & Maria Cecilia SangradorTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Lydia Martinez made an unannounced visit to the facility for the purpose of conducting a Required - 1 Year Annual inspection, with an emphasis on Infection Control due to the COVID-19 pandemic. LPA Martinez was screened upon entry into the facility. LPA met with Administrator Manuel Abadines and Maria Cecilia Sangrado and reason for the visit was explained. AD Abadines confirmed there are currently no cases or exposures of COVID-19 within the facility.

LPA observed the required Department postings on COVID-19 precautions at entrance of facility and/or throughout the facility. There was a sign-in procedure in place and hand sanitizer for use. LPA reminded staff that they should be wearing face masks at all times. The facility has an approved Mitigation Plan on file with CCLD. Four residents were present of which 2 are receiving Hospice services. LPA conducted a tour of the facility and made the following observations: LPA toured resident rooms, all rooms were within regulations. Restrooms observed contained hand washing soap, toilet paper and paper towels. The proper hand washing signs were up in resident/staff bathrooms. Facility has operating smoke and carbon monoxide detectors. Facility's Fire Extinguisher was charged. LPA observed a copy of Administrators Certificate which expires on 08/30/2023. The facility was equipped with sufficient hand hygiene supplies, cleaning and disinfecting provisions. Personal Protective Equipment (PPE) supply is available. The facility monitors the residents regularly for any COVID-19 symptoms/change of condition and documents. Facility has required Emergency Disaster Plan posted. Resident files were reviewed and all documentation was up to date. LPA observed locked medication in medication cart. Facility has a 30 day supply of medications for the residents. LPA noted locked gate separating seating area with back yard.

LPA consulted with staff on the importance of documenting temperature checks, staff wearing face mask and on requesting a Hospice Waiver increase.
Based on observations made during today’s inspection, no deficiencies were noted during today's visit. Exit interview conducted and a copy of this report was emailed during today's visit.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2022
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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