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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209279
Report Date: 10/23/2024
Date Signed: 10/23/2024 12:42:25 PM

Document Has Been Signed on 10/23/2024 12:42 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, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:SAGE CARE 2FACILITY NUMBER:
157209279
ADMINISTRATOR/
DIRECTOR:		BERGSTROM, MERILYNFACILITY TYPE:
740
ADDRESS:13612 NIGHT STAR LN.TELEPHONE:
(661) 332-6079
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93314
CAPACITY: 6CENSUS: 5DATE:
10/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:14 AM
MET WITH:Assistant Administrator, Amy Rawlins and Administrator, Merilyn BergstromTIME VISIT/
INSPECTION COMPLETED:
12:56 PM
NARRATIVE
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On 10/23/2024, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an annual inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA was granted entry to the facility and began the inspection with Assistant Administrator, Amy Rawlins. Administrator, Merilyn Bergstrom, arrived a short time later.

LPA reviewed facility records. Upon review of records, LPA found that S1 had not been cleared prior to working in the facility. LPA contacted CCLD staff and confirmed that S1 has not been cleared to work in the facility. LPA reviewed resident files, including hospice records, and found the records to be current and complete. LPA reviewed personnel records of cleared staff and found the records to be current and complete. LPA reviewed the facility emergency disaster plan. Facility records indicate the last fire drill was conducted on 10/19/2024.

LPA conducted a tour of the facility. Facility appeared clean, odor free, and at a comfortable temperature. Common areas and the dining area had adequate seating and lighting available. Kitchen was toured and observed to be safe for food preparation. LPA observed an adequate food supply. Resident bedrooms were observed to have required furnishings. Bathrooms were toured and observed to be operational. LPA observed securely fastened grab bars and trash cans equipped with lids. Hot water measured at 114.4. Smoke detector and carbon monoxide detector observed to be operational during today's inspection. Exterior tour conducted. All passageways were open and free from obstructions. Side gate was observed to be self-latching.

Medications reviewed and observed to be administered as prescribed.

A deficiency is being issued in accordance to California Code of Regulations, Title 22, Division 6 on the attached 809D. A civil penalty is being assessed in the amount of $100, for background clearance.

Exit interview conducted and a plan of correction was reviewed and developed with Administrator. A copy of this report and appeal rights were discussed and provided to Assistant Administrator, whose signature on this form confirms receipt of this document.
LPA is requesting the following documents be submitted to the Fresno CCL office by 11/06/2024: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E), Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A), Surety Bond
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2024
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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Document Has Been Signed on 10/23/2024 12:42 PM - It Cannot Be Edited


Created By: Alexandria Walton On 10/23/2024 at 12:22 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: SAGE CARE 2
FACILITY NUMBER: 157209279

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above when 1 out of 2 staff present in the facility did not have a criminal record clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/24/2024
Plan of Correction
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Licensee agrees to submit a written statement detailing the steps the facility will take to ensure the requirements for section 87355 are met to the Fresno CCL office by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Melinda Hoffmann
LICENSING EVALUATOR NAME:Alexandria Walton
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2024


LIC809 (FAS) - (06/04)
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