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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336411257
Report Date: 05/28/2021
Date Signed: 05/28/2021 01:13:07 PM

Document Has Been Signed on 05/28/2021 01:13 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: 4DATE:
05/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Mariana Mihailovici, LicenseeTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Deborah Mullen conducted an unannounced annual inspection. LPA met with Mariana Mihailovici, Licensee, and was provided a tour of the home. The home is approved for 6 non-ambulatory residents, of which 3 may be bedridden. The home has a hospice waiver for 4 residents and is approved for locked perimeters.

The home is a five bedroom, 3 bath home with a front living room, family room and kitchen/dining room area. Each bedroom has a bed, dresser, chair and appropriate lighting. The food supply was observed to have 7 days non-perishable and 2 days perishable supply. The medications are locked and stored in a kitchen cabinet and the chemicals/toxins are locked and stored under the kitchen sink and in the garage. The backyard is completely fenced and tables and chairs with shaded areas are available for residents use.

LPA reviewed infection control policies and practices with Licensee during the inspection.

The home is in compliance with Title 22 regulations and no deficiencies were observed or cited.

An exit interview was conducted was a copy of this report was reviewed with and provided to the licensee.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Deborah Mullen
LICENSING EVALUATOR SIGNATURE: DATE: 05/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/28/2021
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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