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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609535
Report Date: 10/30/2023
Date Signed: 10/31/2023 08:18:01 AM

Document Has Been Signed on 10/31/2023 08:18 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
WOODLAND HILLS S.ASC, 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:
10/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Ester FajotaTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced annual visit and was greeted by the Administrator. The facility is licensed as an adult residential facility to serve four ambulatory clients. The Administrator confirmed there are no clients living in the facilty and they are waiting for clients from the Regional Center.

LPA and the manager began the tour of the facility at 10:00 am until 10:30 am. LPA observed the following:

Dining Room– LPA Spaeth observed dining room furniture.

Kitchen - LPA Spaeth observed a seven-day supply of non-perishable food and a two-day supply of perishable foods. The fire extinguisher is located in the kitchen.

Bathroom – LPA Spaeth observed the bathroom contained hand soap, paper towels, and a trash can. The water temperature was tested at 11:00 am and was 105.0 F.

Bedrooms – LPA Spaeth observed there are two client bedrooms in the facility. The bedrooms contained two twin beds in each room, linens, night stand, chair, chest of drawers, closet, and night lamp.

Staff Room – LPA observed the staff room was locked.

Laundry Room – LPA Spaeth observed the laundry room was locked and contained a washer and dryer and a locked cabinet which contained laundry detergent, and cleaning solutions

Hallway Closet - LPA observed the closet was locked and contained clients’ medication bins, first aid kit, and PPE supplies.

Garage - LPA observed the emergency water supply, and an additional refrigerator with additional food

Cont'd 809-C

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: SAGE TREE RESIDENTIAL CARE HOME
FACILITY NUMBER: 197609535
VISIT DATE: 10/30/2023
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Backyard – LPA Spaeth observed comfortable seating in a shaded area. The side gate leading from the backyard to the front yard was not locked.

Smoke and Carbon Monoxide Detectors – The smoke and carbon monoxide detectors were tested at 11:05 am and are operational. .

There are no deficiencies at this time.



Exit interview conducted, and a copy of the signed report was given to caregiver.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023
LIC809 (FAS) - (06/04)
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