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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700994
Report Date: 03/29/2021
Date Signed: 03/29/2021 11:53:45 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:AMETHYST GROVE ASSISTED LIVINGFACILITY NUMBER:
312700994
ADMINISTRATOR:ALLEN, MARCFACILITY TYPE:
740
ADDRESS:2145 CUMBERLAND LOOPTELEPHONE:
(916) 743-4950
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:6CENSUS: 0DATE:
03/29/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Marc AllenTIME COMPLETED:
11:30 AM
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Licensing Program Analyst(LPA) Hiratsuka, contacted the facility via telephone due to COVID-19 and pre-cautionary measures. The purpose of this call is conducting an announced prelicensing visit. LPA spoke to Applicant/Administrator Marc Allen.

This facility has a fire clearance for five non-ambulatory and one bedridden for a total of six residents. This facility has five resident rooms. The main entrance opens into a foyer. To the left is a short hallway that has two private resident rooms and one full common bathroom. There is a private resident room on the left that is not part of the hallway. To the right there is a hallway that leads to one private resident room, one full common bathroom, laundry room that leads to the garage, and the shared resident room that has an exit to the outside and also a full private bathroom. The laundry room is locked. Medications are going to be stored in the locked laundry room. Across the main entrance there is a doorway that leads to the open concept dining, kitchen, and sitting area. There is a locked cabinet for sharp knives in the kitchen. There is a sliding glass door that leads to the outside. This facility does not have a staff room so therefore there shall be awake staff at all times.

-Component III orientation was conducted today.
-questions applicants had were answered.
-several topics were discussed.

This facility meets all regulations. LPA is going to submit this report to the application specialist for final review.

LPA is going to email a copy of this report to Administrator and Administrator is to sign, and email a copy back to LPA.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2021
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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