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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700994
Report Date: 10/16/2024
Date Signed: 10/16/2024 02:52:06 PM

Document Has Been Signed on 10/16/2024 02:52 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
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME:AMETHYST GROVE ASSISTED LIVINGFACILITY NUMBER:
312700994
ADMINISTRATOR/
DIRECTOR:		ALLEN, MARCFACILITY TYPE:
740
ADDRESS:2145 CUMBERLAND LOOPTELEPHONE:
(916) 250-1128
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY: 6CENSUS: 6DATE:
10/16/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Marc Allen, LicenseeTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On 10/16/2024 Licensing Program Manager (LPM) Troy Ordonez, LPM Anthony Perez, Regional Manager Alycia Rayner, Licensing Program Analyst (LPA) Bethany Mirlohi, and LPA Cassandra Mikkelson met with Licensee Marc Allen, and potential new licensee Mary and Alex Bot via teleconference to discuss change of ownership of facility.

Mary and Alex are in the process of submitting a new application for new ownership of facility. Licensee understands during this process of change of ownership he remains the licensee and that his license is not transferable. Licensee informed CCL that Mary and Alex are now in control of the property with a lease agreement. Licensee agrees to the following:

  1. Licensee will provide residents with the ombudsman and placement agency contact information in case the residents choose to seek new residence.
  2. Licensee to submit into LPA form LIC308 in order to change Administrator to Mary Bot.
  3. Licensee to ensure Mary and Alex are fingerprint cleared and associated to the facility. Licensee to submit into LPA the LIC9182 for Mary Bot.
  4. Mary and Alex Bot to submit a copy of the new lease agreement into LPA.
  5. Mary and Alex Bot to submit their application into the Centralized Application Unit by October 31, 2024. In addition, Mary to submit the contact information for the company assisting them with the application process.

LPA will forward a copy of this report to licensee. Licensee to review report, sign, and return a signed copy to CCL.

Exit interview conducted.

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE: DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2024
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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