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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336411257
Report Date: 05/17/2022
Date Signed: 05/17/2022 04:06:44 PM


Document Has Been Signed on 05/17/2022 04:06 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:AGATE MANORFACILITY NUMBER:
336411257
ADMINISTRATOR:MARIANA MIHAILOVICIFACILITY TYPE:
740
ADDRESS:33391 AGATE STTELEPHONE:
(951) 672-2595
CITY:MENIFEESTATE: CAZIP CODE:
92584
CAPACITY:6CENSUS: 5DATE:
05/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:06 PM
MET WITH:Licensee- Mariana MihaloviciTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA), Janira Arreola made an unannounced visit to the facility to conduct an annual inspection focused on infection control. LPA was greeted and granted entry by S1,and met with Licensee Mariana Mihailovici, who was informed of the purpose of the visit. At the time of visit there were 3 staff and 5 residents present. The facility currently has zero positive or suspected Covid-19 cases.

During today's visit, LPA toured the facility and made observations regarding the infection control measures that the facility has implemented. LPA did not observe Covid-19 postings and advised licensee to post them around the facility. A single entry point was designated and LPA advised Licensee to start documenting temperatures for all visitors, residents, and staff. The facility had a plan in place to monitor residents regularly for any changes in condition. The facility had an adequate amount of hand hygiene supplies (soap and hand sanitizer) in all restrooms and advised Licensee to use paper towels instead of cloth towels. Common areas such as dining rooms and activity rooms have been modified with social distancing and masking policies. There are designated isolation rooms and a plan in place to monitor and attend to those in the isolation rooms. LPA advised Licensee to obtain more PPE equipment to have a sufficient 30-day supply. LPA also advised Licensee to get staff N95 FIT tested. The facility also has a designated infection control lead and a plan in place to clean and disinfect the highly touched surfaces. LPA advised licensee to have staff and visitors at the facility wear masks at all times.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2022
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: AGATE MANOR
FACILITY NUMBER: 336411257
VISIT DATE: 05/17/2022
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LPA advised Licensee to update her LIC500 and submit it to LPA as soon as possible. LPA will give technical violation for this since LIC500 was observed for all other years at the facility.

LPA also advised Staff and Licensee to label hygiene products in resident bathrooms.

LPA spoke with S1 and they stated that staff have a designated staff room in the garage. LPA was able to review Facility sketch and verify that this was approved by the department and permitted at the facility.

There were no deficiencies noted at the time of the visit. An exit interview was conducted, and a copy of this report was reviewed and provided to facility licensee, Mariana Mihailovici.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022
LIC809 (FAS) - (06/04)
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