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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602480
Report Date: 08/31/2022
Date Signed: 08/31/2022 09:46:10 AM

Document Has Been Signed on 08/31/2022 09:46 AM - 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:
08/31/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Maria Rina Chang, LicenseeTIME COMPLETED:
10:00 AM
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Licensing Program Analyst, Sabel Martinez, and County of San Diego Registered Nurse, Sandra Brackman, with the HAI Program, conducted an on-site visit. The team identified themselves and discussed the purpose of the visit with Licensee, Maria Rina Chang.

The Department and HAI Team conducted the on-site visit to provide technical assistance and to evaluate the facility's disinfection, surveillance testing, screening protocols as well as the use of personal protective equipment. During today's visit, the team conducted a walk-through of the facility. A debriefing was conducted with the Licensee at the conclusion of the visit. During today's visit, no deficiencies were issued.

An exit interview was conducted with Licensee, Maria Rina Chang, to whom a copy of this report and Licensee Rights (LIC 9058 01-2016) were provided to.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2022
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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