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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609535
Report Date: 07/11/2022
Date Signed: 07/11/2022 05:19:41 PM

Document Has Been Signed on 07/11/2022 05:19 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:SAGE TREE RESIDENTIAL CARE HOMEFACILITY NUMBER:
197609535
ADMINISTRATOR:FAJOTA, ESTER PFACILITY TYPE:
735
ADDRESS:38591 SAGE TREE STREETTELEPHONE:
(661) 794-2188
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 4CENSUS: 0DATE:
07/11/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Nestor Fajota TIME COMPLETED:
11:00 AM
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LPA Spaeth conducted an unannounced visit to the facility and was greeted by Nestor Fajota (S1). LPA Spaeth stated the purpose of the visit was to conduct a case management visit in regard to the family dog which is housed in the backyard of the facility. S1 confirmed there are no residents at the facility due to North Los Angeles Regional Center's final approval of the facility. Upon entering the facility, LPA's temperature was taken and LPA answered the COVID questions.

At 10:45 am, LPA was escorted to the sliding glass door that leads to the backyard. S1 stated will place the dog in the locked section of the backyard. Upon locking the dog in the secure area, LPA was escorted to the backyard and observed the dog was securely locked at the side of the facility. LPA approached the locked gate and LPA observed the dog barked but did not show any aggressive behavior. LPA walked to the other side of the yard and then walked back to the locked area. LPA observed the dog did not bark.

LPA asked the procedures that the staff will follow when residents move into the facility. S1 stated dog will be safely locked in the backyard area at all times. S1 stated the residents will be instructed not to pet dog when going out to the backyard. S1 also stated a "beware of dog" sign will be placed at the locked gate.

Based upon LPA's observations of the dog and the locked area for safely keeping the dog in a desginated area of the backyard, LPA did not observe any issues.

There are no deficiencies to report at this time. Exit interview conducted, appeal rights discussed, and a copy of the printed report was given to S1.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2022
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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