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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209279
Report Date: 10/26/2022
Date Signed: 10/26/2022 10:56:13 AM


Document Has Been Signed on 10/26/2022 10:56 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814



FACILITY NAME:SAGE CARE 2FACILITY NUMBER:
157209279
ADMINISTRATOR:BERGSTROM, MERILYNFACILITY TYPE:
740
ADDRESS:13612 NIGHT STAR LN.TELEPHONE:
(661) 410-8417
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93314
CAPACITY:6CENSUS: 6DATE:
10/26/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Merilyn Bergstrom(Applicant/Administrator)TIME COMPLETED:
10:20 AM
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Facility Type: RCFE
Application Type: CHOW
Capacity: 6
Census (if any clients in care): 6

COMP II Participants: Merilyn Bergstrom(Applicant/Administrator)

Interview Method: Telephone interview with CAB

Applicant/Administrator participated in COMP II. During COMP II, Applicant/ Administrator confirmed the understanding of the California Code Title 22 Regulations.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Applicant and Administrator qualifications
3. Staff Qualifications - hiring procedures, responsibilities; training
4. Program policies -restricted/prohibited health conditions, medication management; incident reporting to CCLD; food service and management, Activities program
5. Grievances, Complaints, Community resources; Abuse reporting
6. Application document review and technical assistance- Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator Certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of property
SUPERVISOR'S NAME: Tracy ThompsonTELEPHONE: (916) 657-2025
LICENSING EVALUATOR NAME: Ricmar SorianoTELEPHONE: (916) 617-7083
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2022
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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