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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209405
Report Date: 11/21/2024
Date Signed: 11/21/2024 01:18:34 PM

Document Has Been Signed on 11/21/2024 01:18 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 HOMESFACILITY NUMBER:
157209405
ADMINISTRATOR/
DIRECTOR:		BERGSTROM, MERILYNFACILITY TYPE:
740
ADDRESS:13601 STAR SHINE DR.TELEPHONE:
(661) 332-6079
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93314
CAPACITY: 6CENSUS: 4DATE:
11/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:06 PM
MET WITH:Administrator, Merilyn BergstromTIME VISIT/
INSPECTION COMPLETED:
01:32 PM
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On 11/21/2024, 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. Facility staff granted LPA entry to the facility and contact Administrator, Merilyn Bergstrom, via telephone. Administrator arrived a short time later. LPA met with Administrator.

LPA reviewed facility records and observed the following: Resident records were observed to be current and complete. Staff records were observed to be current and complete. Staff training was observed to be up to date. Emergency disaster plan reviewed and observed to be up to date. Last documented fire drill was conducted on 10/25/2024. Medications were reviewed. Facility utilizes an electronic medication administration record (MAR). Medications observed to be administered as prescribed.

Facility tour conducted with Administrator. Facility observed to be clean and odor free. Common areas including the dining area observed to have adequate furnishings and lighting available. Smoke detector and carbon monoxide detector were observed to be operational. Kitchen toured. Kitchen observed to be clean and safe for food preparation. LPA observed an adequate food supply. Knives/sharps observed to be locked in a lock box inaccessible to residents in care. Cleaning supplies observed to be locked and inaccessible in the laundry room. Resident bedrooms toured. Bedrooms were observed to have required furnishings. Resident bathrooms toured. Bathrooms were equipped with securely fastened grab bars. Facility is equipped with a tank-less water heater programmed to maintain water temperature at 120 degrees F. Hot water measured at 118.0 degrees F. LPA observed an adequate supply of linens and hygiene products. Exterior tour conducted. All exits open and free from obstructions. No fire clearance issues observed during today's inspection.

No deficiencies issued. Exit interview conducted. A copy of this report was discussed and provided to Administrator, Merilyn Bergstrom, via email due to technical issues. Administrator informed that a hard copy of the report will be mailed to the facility. Report was signed on-site by facility representative.

LPA is requesting the following documents be submitted to the Fresno CCL office by 12/05/2024: 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: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2024
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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