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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530149
Report Date: 03/22/2024
Date Signed: 03/22/2024 11:03:30 AM


Document Has Been Signed on 03/22/2024 11:03 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:AGATE HOMECAREFACILITY NUMBER:
335530149
ADMINISTRATOR:SANASINH, ALOUNKONE BROOKEFACILITY TYPE:
740
ADDRESS:13968 AGATE COURTTELEPHONE:
(951) 220-7143
CITY:EASTVALESTATE: CAZIP CODE:
92880
CAPACITY:6CENSUS: DATE:
03/22/2024
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Brooke Sanasinh/AdministratorTIME COMPLETED:
11:06 AM
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Licensing Program Analyst (LPA) Bianca Wolcott conducted an announced visit to the facility for the purpose of verifying corrections from the intial Pre-Licensing inspection on February 22, 2024. At approximately 9:00 AM, LPA was greeted and granted entry by Administrator Brooke Sanasinh. LPA observed the following:

Non-ambulatory residents were changed by physicians report signed 2/28/24 to ambulatory residents, this was confirmed by viewing physicians report signature page included and touring the facility and inspecting all residents bedrooms.

LIC 602 Admission agreement completed for all residents.

Updated Physician's report for residents diagnosed with dementia.

Pre-licensing is now complete. Final licensor will be determined by Central Application Bureau (CAB). Administer completed COMP III online with Administrator. An exit interview was conducted and a copy of this report provided electronically.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Bianca WolcottTELEPHONE: (951) 248-0306
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2024
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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