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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209279
Report Date: 11/15/2022
Date Signed: 11/15/2022 11:59:37 AM


Document Has Been Signed on 11/15/2022 11:59 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, 1314 E SHAW AVE
FRESNO, CA 93710



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:
11/15/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:14 AM
MET WITH:Administrator, Merilyn BergstromTIME COMPLETED:
12:12 PM
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On 11/15/2022, Licensing Program Analyst (LPA) A. Walton conducted an announced Pre-Licensing / Component III inspection. LPA Walton introduced self, stated purpose of visit, and was allowed entry into the facility. LPA met with Administrator, Merilyn Bergstrom. Facility has one central entry and exit. LPA observed a visitor log / temperature check upon entry.

The facility is a 4 Bedroom and 3 Bathroom home and fire clearance was granted for 6 Non-Ambulatory for a total capacity of 6.

LPA toured the facility with Administrator. Common areas were furnished and had adequate seating and lighting available. Bedrooms had required furnishings and are ready for occupancy. Hot water measured at 109.6 degrees F in bathroom 1 and 112.3 in the bathroom in the shared room. LPA observed an extra supply of bed linens and personal hygiene products. Kitchen was toured and observed to have dishes, plates, and utensils. Cleaning supplies and chemicals were observed in a locked cabinet in the garage. Medications are locked in a closet in the office. First aid kit was observed and contained all required items. A fire extinguisher was observed and has a service date of 07/1/2022. Smoke detectors and carbon monoxide were observed to be operational.

Outside of facility toured. Exits were open and free of obstructions. LPA observed side gate to be self-latching.

Component III was conducted during today’s pre-licensing visit.

I have found that the applicant has met all pre-licensing requirements. LPA will submit documentation to CAB in Sacramento for final review prior to license being issued.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2022
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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