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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336411257
Report Date: 05/16/2024
Date Signed: 05/16/2024 12:53:46 PM


Document Has Been Signed on 05/16/2024 12:53 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:AGATE MANORFACILITY NUMBER:
336411257
ADMINISTRATOR:DENISE GILROYFACILITY TYPE:
740
ADDRESS:33391 AGATE STTELEPHONE:
(951) 672-2595
CITY:MENIFEESTATE: CAZIP CODE:
92584
CAPACITY:6CENSUS: 4DATE:
05/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Licensee, Mariana MihailoviciTIME COMPLETED:
01:00 PM
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On 5/16/2024 Licensing Program Analysts (LPAs) Janette Romero and Valerie Flores conducted an unannounced annual required visit. LPAs met with Licensee, Mariana Mihailovici who was informed of the purpose of the visit. The facility is licensed to care for six (6) non-ambulatory residents of which three (3) may be bedridden. The facility currently has a total of four (4) residents for which two (2) are receiving hospice care and one (1) is receiving home health services at the facility. Staff present have a criminal record clearance and are associated to the facility.

LPAs conducted a tour of the facility with Licensee. Indoor and outdoor passageways are free of obstructions. There are no bodies of water. The facility has more than a two (2) day supply of perishable foods and seven (7) day supply of non-perishable foods. LPAs observed a second refrigerator with perishable foods and emergency food and water stored in the garage. Resident bedrooms had the required bedding, furniture, and lighting. Resident bathrooms had grab bars and non-skid mats in the showers. Disinfectants and cleaning solutions were secured in the locked laundry room. Licensee tested one of the carbon monoxide/smoke detectors and LPAs observed it to be operational. LPAs observed charged fire extinguishers mounted throughout the facility. The facility has door alarms as a safety measure to identify wandering behaviors and LPAs were informed that none of the current residents display wandering behaviors. LPAs reviewed the medication administration record along with the physical medications for two (2) residents and did not discover any discrepancies. LPAs also reviewed random staff and resident files. Staff files reviewed have a criminal record clearance and valid first aid/CPR certification. Resident files review have signed admission agreements and updated physician reports. Facility sketch and Long-Term Care Ombudsman's information is posted near the entrance and living room.

During today's visit, LPAs did not observe any issues or concerns. An exit interview was conducted and a copy of this report was reviewed and provided to Licensee.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: (951) 529-2930
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2024
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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