335530149-2-22-2024-56-AS-BWOT-D2PU83-20240222142051

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 335530149
Report Date: 02/22/2024
Date Signed: 02/22/2024 02:21:02 PM

Document Has Been Signed on 02/22/2024 02:21 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	AGATE HOMECARE		FACILITY NUMBER:	335530149
ADMINISTRATOR:	SANASINH, ALOUNKONE BROOKE		FACILITY TYPE:	740
ADDRESS:	13968 AGATE COURT		TELEPHONE:	(951) 220-7143
CITY:	EASTVALE	STATE: CA	ZIP CODE:	92880
CAPACITY:	6	CENSUS: 6	DATE:	02/22/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:54 AM
MET WITH:	Simm Sanasinh/Administrator		TIME COMPLETED:	02:35 PM

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 Analysts (LPAs) and Bianca Wolcott and Anna Bueno made a visit to the facility for the purpose of conducting a pre-licensing inspection visit. LPAs met with Administrator Simm Sanasinh. LPAs and Administrator toured the facility inside and out. The pending initial application is for a change of ownership a Residential Care Facility for the Elderly/Dementia (RCFE). Fire Clearance inspection was completed on 7/13/2023 and the property has been granted a fire clearance for a maximum capacity of six (6) which are two (2) ambulatory residents and four (4) non ambulatory only. Facility is a single story home with 5 bedrooms, 3 bathrooms, living room, dining room, and kitchen. There are no bodies of water. Appropriate patio furniture was present. LPAs observed proper required accommodations in resident bathrooms. Smoke detectors were operable. Carbon monoxide device was operable. Fire extinguisher are charged and last purchased on 12/03/2023. Hot water is kept at 104 degrees F. LPAs observed required postings including Resident's Personal Rights, the Department's complaint poster, the Ombudsman's poster, and the facility's emergency/disaster plan. The kitchen area was observed for the ability to serve food and maintained cleanliness. Temperatures for refrigerator is at 40 degrees and freezer was at 0 degrees. Dishes, utensils, glasses are present and in working order. Dishwasher will be used to clean and sanitize dishes. LPAs observed 2 days of perishable food items and 7 days of non perishable goods. Bedrooms have the required furnishings and sufficient storage space and lighting. Facility has an adequate supply of linens and towel. Medication and resident and staff files will be stored in a locked cabinet and a locked cabinet for medications. One complete first aid kit was observed in the kitchen. CONTINUED ON LIC812-C

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Bianca Wolcott	TELEPHONE: (951) 248-0306
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: AGATE HOMECARE	FACILITY NUMBER: 335530149
	VISIT DATE: 02/22/2024

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LPAs did not observe any potential hazards within the facility at the time of visit. The property appears to be in good repair and safe for resident use.

The facility currently has six (6) clients in care, two (2) ambulatory and four (4) non-ambulatory of which are elderly. The following corrections need to be performed before the pre-licensing inspection is completed:

LIC 602 Admissions agreement needs to be completed for five (5) residents.
Non Ambulatory residents will be removed from Ambulatory rooms
Updated Physician's report for resident diagnosed with dementia.
Continuing record of needed services.

An exit interview was conducted where this report was discussed and a copy was provided to Administrator Simm Sanasinh/Administrator.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Bianca Wolcott	TELEPHONE: (951) 248-0306
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024

LIC809 (FAS) - (06/04)

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