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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209279
Report Date: 08/04/2023
Date Signed: 08/04/2023 12:35:39 PM


Document Has Been Signed on 08/04/2023 12:35 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, 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:
08/04/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator, Merilyn BergstromTIME COMPLETED:
12:46 PM
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On 08/04/2023, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct a Post-Licensing Inspection. LPA introduced self, stated that purpose of the visit and was allowed to enter the facility. LPA met with Administrator, Merilyn Bergstrom.

LPA conducted a tour inside and outside the facility. LPA observed the following:

Facility currently has 6 residents. Facility observed to be clean, odor free, and at a comfortable temperature. The dining room and living room were furnished well with adequate seating and lighting. Resident rooms appeared clean and had all required furnishings. LPA observed an adequate supply of linen. Resident bathrooms were properly equipped with securely fastened grab bars and non-skid mats. Hot water measured at 116 degrees F in the shared bedroom and 115.5 degrees F in the hallway bathroom. Kitchen toured, appeared clean, observed a 7-day supply of non-perishable and 2-day supply of perishable food. Knives/Sharps observed to be locked and inaccessible. Exterior tour conducted, all exits open and free of obstructions. Side gate was observed to be self-latching.

Smoke detectors and carbon monoxide detectors observed operational during today’s inspection. Last fire drill conducted on 07/18/2023. All chemicals observed to be locked and secure. Medications observed to be locked in a closet and administered as prescribed.

No deficiencies issued during today's visit. Exit interview conducted. A copy of this report was discussed and provided to Administrator, Merilyn Bergstrom, whose signature on this form confirms receipt of this document.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2023
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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