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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603727
Report Date: 01/31/2022
Date Signed: 01/31/2022 05:12:35 PM

Document Has Been Signed on 01/31/2022 05:12 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 VILLAFACILITY NUMBER:
374603727
ADMINISTRATOR:MARY JANE ESTILLERFACILITY TYPE:
740
ADDRESS:12285 FRONTERA ROADTELEPHONE:
(858) 348-7791
CITY:SAN DIEGOSTATE: CAZIP CODE:
92128
CAPACITY: 6CENSUS: DATE:
01/31/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Licensee, Rina ChangTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA), Natasha Persaud and County of San Diego Nurse Contractor, Robert Montillano conducted an on-site visit. LPA and Nurse identified themselves and discussed the purpose of the visit with Licensee, Rina Chang.

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

An exit interview was conducted with the Licensee and a copy of this report, along with Licensee Rights (LIC 9058 01/16), were provided to the Licensee via electronic mail. An electronic receipt of confirmation was requested to be sent by the Licensee upon receipt of the documents.
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2022
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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