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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 05:20:16 PM

Document Has Been Signed on 07/11/2022 05:20 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:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Nestor FajotaTIME COMPLETED:
12:00 PM
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LPA Spaeth conducted an unannounced visit and was greeted by staff member Nestor Fajota (S1). LPA stated the purpose of the visit was to conduct an annual visit. LPA’s temperature was taken and LPA observed the sign in station which contained sign in sheet, thermometer, hand sanitizer and surgical masks. S1 confirmed there are no residents at the facility at this time. LPA began the tour at 11:00 am with S1. S1 stated the living room would be used for residents to watch television. LPA observed comfortable seating along with a television. LPA was escorted to the kitchen and observed wash your hands sign, hand soap, paper towels and a trash can located near the kitchen sink. LPA observed the cabinet underneath the sink did not contain any cleaning supplies or harmful items at that location. The knives were safely locked in a kitchen drawer. The refrigerator contained a five day supply of fruits and vegetables. The pantry was stocked with a seven day supply of canned goods and pasta. LPA also observed the fire extinguisher. LPA observed a family room/dining room combination which contained a kitchen table with chairs. S1 stated this can be used for eating and also for the residents to play games. LPA was escorted outside and observed the family dog was locked in a secure area. S1 stated the dog will be locked in this area when residents move into the facility. The side gate that leads to the front yard was not locked. The backyard also contained comfortable seating.

LPA observed the facility bathroom which contained wash your hands sign, hand soap, paper towels, and a trash can. There are two resident rooms which both contained twin beds which were six feet apart. The rooms also contained bedding, chair, night stand, a lamp, chest of drawers, and closet.

The staff room is the master bedroom. The room was locked and also contains the master bathroom. LPA observed a locked door which leads to the garage. The laundry room contains a locked cabinet which contains the laundry soap and cleaning supplies. A hallway cabinet was locked and is designated for residents’ medications, PPE supplies, and the first aid kit. Upon conclusion of the tour, LPA did not observe any deficiencies.

Exit interview conducted, appeal rights, discussed, and a copy of the 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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