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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602480
Report Date: 12/06/2021
Date Signed: 12/06/2021 01:55:09 PM

Document Has Been Signed on 12/06/2021 01:55 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:SAGE GARDEN AT RANCHO BERNARDO, THEFACILITY NUMBER:
374602480
ADMINISTRATOR:MARIA RINA CHANGFACILITY TYPE:
740
ADDRESS:12295 FRONTERA RDTELEPHONE:
(858) 716-3947
CITY:SAN DIEGOSTATE: CAZIP CODE:
92128
CAPACITY: 6CENSUS: 5DATE:
12/06/2021
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Licensee, Rina ChangTIME COMPLETED:
01:35 PM
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Licensing Program Analyst (LPA) Natasha Persaud and Regional Manager (RM), Icela Estrada conducted a virtual Informal Meeting with Licensee, Rina Chang. The purpose of the meeting was to discuss a recently issued deficiency involving criminal record clearance.

During the meeting, the following items were discussed: Criminal Record Clearances and staffing. Licensee explained at this time the facility has sufficient staffing. Licensee was made aware Staff #1 (S1) is not allowed to work, reside or be present in the facility without an approved criminal record exemption. Licensee has agreed not to allow S1 to be present in the facility, work or reside.

LPA provided the licensee with the Home Care Organization list for staffing resources via email.

An exit interview was conducted with the Licensee and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided to the Licensee via electronic mail.
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2021
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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