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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609535
Report Date: 07/25/2024
Date Signed: 07/25/2024 04:02:05 PM

Document Has Been Signed on 07/25/2024 04:02 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:SAGE TREE RESIDENTIAL CARE HOMEFACILITY NUMBER:
197609535
ADMINISTRATOR/
DIRECTOR:		FAJOTA, ESTER PFACILITY TYPE:
735
ADDRESS:38591 SAGE TREE STREETTELEPHONE:
(661) 794-2188
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 4CENSUS: 1DATE:
07/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Ester FajotaTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced visit and was greeted by the Licensee/Administrator, Ester Fajota. LPA stated the purpose of the visit is to conduct an annual inspection. The facility is licensed for four ambulatory clients. The Administrator confirmed there is one client.

LPA and the Licensee toured the facility at 10:15 am until 11:30 am. LPA Spaeth observed the following:

Common Areas - LPA observed comfortable seating and a television in the living room. The dining room contained a dining room table, chairs, the fire extinguisher, and a comfortable couch.

Kitchen - LPA Spaeth observed a two day supply of perishable food and a seven-day supply of non-perishable canned goods. At 10:20 am, LPA observed the knives were safely locked in a kitchen drawer. The kitchen was neat and clean.

Backyard –The backyard contained comfortable seating in a shaded area. The gate leading from the backyard to the front yard was not locked.

Laundry Area – The laundry room contained the washer/dryer, and the laundry detergent and cleaning solutions were locked in a cabinet.



Garage – The door leading to the garage was locked and the garage contained an additional refrigerator, and emergency supply of water and food.

Hallway - The hallway contained a linen drawer which contained additional clean linens. LPA observed the medication closet was locked and contained the client's medication, first aid kit, client and staff records.

Continued 809-C
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 07/25/2024
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Client Rooms– There are two clients’ rooms. Both rooms contained two twin beds, linens, chairs, night stand, light, and a closet. LPA observed the client was in their room working on their computer.

Bathroom - LPA observed the bathroom was clean and contained hand soap, covered trash can, paper towels, and grab bars.

Smoke/Carbon Monoxide Detectors - The smoke detector and the carbon monoxide detector were both tested at 11:30 am and both were properly working.

Client’s Records -LPA reviewed the client’s records at 11:30 am until 12:00 pm



Staff Records - LPA reviewed staff records at 12:15 pm until 12:45 pm.

There are no deficiencies to report at this time. Exit interview was conducted and a copy of the report was given.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024
LIC809 (FAS) - (06/04)
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