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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700994
Report Date: 05/03/2022
Date Signed: 05/03/2022 03:24:59 PM


Document Has Been Signed on 05/03/2022 03:24 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926



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: 4DATE:
05/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Marc AllenTIME COMPLETED:
03:35 PM
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Licensing Program Analyst (LPA) Kerry Hiratsuka arrived at the facility unannounced on 05/03/2022, to conduct a Annual Visit in response to an incident reported yesterday by the facility. LPA conducted COVID-19 Precautionary prescreening, and wore a surgical mask while at facility. LPA was screened by Caregiver and House Manager.

LPA and House Manager, toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, and common restrooms. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Administrator completed the infection control domain and facility was found to be in substantial compliance at this time.

One resident and one staff record were reviewed during today's visit

Multiple topics were discussed.

The following shall be updated and submitted to Community Care Licensing Division by May 20, 2022:
-LIC 308 designation of administrative responsibility
-staff schedule or LIC 500
-copy of liability insurance
-LIC 610e emergency mass disaster plan

No deficiencies are being cited as a result of todays inspection.

Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2022
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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