306005369-10-9-2026-22-AS-RMRT-DYPP3F-20261009105728

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005369
Report Date: 10/09/2026
Date Signed: 10/09/2026 10:57:46 AM

Document Has Been Signed on 10/09/2026 10:57 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	AMETHYST CARE HOME @ VIRGINIA		FACILITY NUMBER:	306005369
ADMINISTRATOR/ DIRECTOR:	MISA, MARIA TERESA, C		FACILITY TYPE:	740
ADDRESS:	2720 EAST VIRGINIA		TELEPHONE:	(657) 201-3276
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92806
CAPACITY: 6		CENSUS: 3	DATE:	10/09/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:00 AM
MET WITH:	Zenaida Lopez, Staff		TIME VISIT/ INSPECTION COMPLETED:	11:15 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to conduct an Annual Required Evaluation. LPA was greeted and granted entry by staff at 8am and explained the purpose of the visit. Administrator (AD) Jinky Hilario was unable to be at the facility but authorized staff to sign the reports. The facility is a six bedroom, two bathroom home with an approved fire clearance for six non-ambulatory residents; in which one may be bedridden. The facility has a hospice waiver for three residents. Currently two residents receive hospice serves. There are three residents in care. Four bedrooms are used for residents and two bedrooms are used by live-in staff. During the visit, LPA inspected the smoke and carbon monoxide detectors. Both smoke and carbon monoxide detectors were operational. The fire extinguisher was charged and inspected on August 19, 2025. The facility conducted a quarterly fire drill on October 2, 2026. The facility was 76 degrees Fahrenheit. LPA toured resident bedrooms and observed they were clean, had dressers, ample closet space, lights and bed linens. There were no odors detected. LPA tested the hot water temperature in two of two resident bathrooms. The hot water temperatures ranged between 106.2 to 107.7 degrees Fahrenheit. Bathrooms had grab bars, non-skid flooring and covered trash cans. LPA observed the kitchen was clean and sharps and knives were secured, as well as hazardous chemicals, underneath the sink. A laundry area had a washer and dryer that were operational and detergents were secured. (Continued on LIC 809-C)

Alisa Ortiz
RoseMarie Ruppert
	DATE: 10/09/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: AMETHYST CARE HOME @ VIRGINIA	FACILITY NUMBER: 306005369
	VISIT DATE: 10/09/2026

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(Continued from LIC 809)

Fresh fruit were on the dining table and the refrigerator had more than two days of perishables and the pantry had seven days of non-perishables available. Emergency supplies were observed.

LPA toured the exterior of the property and there was ample space for outdoor activities. There were no hazards or obstructions blocking pathways and an exterior self-latching gate was in working order. There was a shaded seating area and there were plenty of plants in the backyard.

Centrally stored medications were secured in a cabinet. LPA reviewed centrally stored medications and medications are being given as prescribed. The First Aid Kit had the required elements and a First Aid pamphlet was observed. The PUB 475 poster, as well as the Long Term Care Ombudsman poster, were posted at the front entry.

LPA reviewed three of three staff training and fingerprint records and conducted a complete review of resident records. LPA interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that administrator has a current administrator certificate which expires on July 3, 2028.

Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Zenaida Lopez, Staff and a copy of the report and files reviewed (LIC 858 & LIC 859) were given at the time of the visit.

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: RoseMarie Ruppert
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/09/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2026

LIC809 (FAS) - (06/04)

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