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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602480
Report Date: 07/07/2022
Date Signed: 07/07/2022 03:55:35 PM

Document Has Been Signed on 07/07/2022 03:55 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:MARY JANE ESTILLERFACILITY TYPE:
740
ADDRESS:12295 FRONTERA RDTELEPHONE:
(858) 716-3947
CITY:SAN DIEGOSTATE: CAZIP CODE:
92128
CAPACITY: 6CENSUS: 6DATE:
07/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Administrator, Maria Rina Chang, Caregivers, Elizabeth Aquino, and Ramil BelarmaTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA), Sabel Martinez, visited the facility to conduct an annual required licensing inspection. The LPA was greeted by Caregivers, Elizabeth Aquino, and Ramil Belarma, identified himself, and disclosed the purpose of the visit. Administrator, Maria Rina Chang, arrived during the visit.

During today's visit, the LPA toured the facility, and verified compliance with infection control practices. The LPA observed one central entry point for universal entry screening; routine symptom screening initiated at entry for staff, residents and visitors; a sign-in policy enacted for all visitors; signs posted at facility entrance with the facility’s visitor policy and signs throughout the facility to promote hand hygiene; face coverings worn by staff; hand sanitizer/hand washing stations readily available; a designated visitation area; emergency agencies’ contact information posted in a location visible to staff and residents; and an adequate supply Personal Protective Equipment (PPE).

Additionally, exterior and interior passageways were free from obstructions. All of the residents’ rooms were equipped with the required furnishings. Residents’ bathrooms were observed to be sanitary and operational. The facility was stocked with a 2-day supply of perishable and a 7-day supply of nonperishable food items. There were no pools, nor bodies of water accessible to residents in care. No deficiencies were cited during today’s visit.

An exit interview was conducted with Administrator, Maria Rina Chang, to whom a copy of this report, along with the Licensee Rights (LIC 9058 FAS 01/16) were provided to.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2022
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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