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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209405
Report Date: 12/11/2023
Date Signed: 12/11/2023 11:29:15 AM


Document Has Been Signed on 12/11/2023 11:29 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 HOMESFACILITY NUMBER:
157209405
ADMINISTRATOR:BERGSTROM, MERILYNFACILITY TYPE:
740
ADDRESS:13601 STAR SHINE DR.TELEPHONE:
(661) 332-6079
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93314
CAPACITY:6CENSUS: 0DATE:
12/11/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:17 AM
MET WITH:Licensee, Merilyn BergstromTIME COMPLETED:
11:33 AM
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On 12/11/2023, Licensing Program Analyst (LPA) Walton arrived for an announced pre-licensing inspection. LPA introduced self, stated the purpose of the visit and was granted entry to the facility. LPA met with Licensee, Merilyn Bergstrom.

This facility is a 4 bedroom and 2 bathroom home and a fire clearance was granted for 6 Non-Ambulatory, for a total capacity of 6.

LPA toured the facility. Common areas were furnished and had adequate seating and lighting available. Bedrooms had required furnishings and are ready for occupancy. Hot water measured at 118.0 degrees F in the hallway bathroom and the bathroom in bedroom 1. 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 to be locked and inaccessible in a closet in the laundry room. Medications will be locked in a cabinet in the office/visiting room. First aid kit was observed and contained all required items. A fire extinguisher was observed and has a service date of 10/24/2023. Smoke detectors and carbon monoxide detector were observed to be operational.

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

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: 12/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2023
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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