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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603413
Report Date: 03/04/2021
Date Signed: 03/04/2021 03:25:18 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SAGE GLENDALE SENIOR LIVINGFACILITY NUMBER:
198603413
ADMINISTRATOR:BERARD, MARTHAFACILITY TYPE:
740
ADDRESS:525 W. ELK AVETELEPHONE:
(818) 858-4557
CITY:GLENDALESTATE: CAZIP CODE:
91204
CAPACITY:113CENSUS: 0DATE:
03/04/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Elizabeth Whittington (Executive Director)TIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Kruz Long conducted an announced Pre-licensing inspection. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today's inspection was conducted via Facetime (Video Conference) with Executive Director Elizabeth Whittington.

An application was received for initial License #198603413, Residential Care Facility for the Elderly. Age range 60 and over. 113 Non-ambulatory, of which 9 may be bedridden. Approved for delayed egress on 2nd floor. All rooms approved for bedridden. Hospice waiver for 2.

The facility is a 5 story building with underground parking. 1st floor contain common areas. 2nd floor is for Memory Care. 3rd to 5th floor is for Assisted Living. During today's inspection, LPA observed the following:

· There are outdoor shaded area.
· Passageways, stairways, walkways, driveway and steps are free of debris and obstructions.
· Facility is clean, sanitary and in good repair.
· Bedrooms are large enough to accommodate furniture.
· Bathrooms have working toilets, wash basins, showers, grab bars and non-skid floors.
· Hygiene supplies are available for resident use.
· Emergency Phone Numbers, Exit Plan & Menu are posted & readily available for review.
· Fire Extinguishers are fully charged.

Continue to LIC809C........

SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz LongTELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2021
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SAGE GLENDALE SENIOR LIVING
FACILITY NUMBER: 198603413
VISIT DATE: 03/04/2021
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· Smoke Detectors and Carbon monoxide detectors are operational.
· Water Temperature measured within Title 22 guidelines in all floor.
· Kitchen contain the necessary food supplies.
· First aid kit is available on all floors.
· There are no Pool/Jacuzzi on the premises.
· Medications will be centrally stored in the Nurse's station.
· Chemicals agents are safely secured and inaccessible to residents.
· Each resident's room has it's own thermostats and alert button.
· Cameras are located on the exteriors of the facility and in the underground parking area.

Fire Safety Clearance was granted on 01/28/21.

Component III: Waved: Licensee is currently operating under License #565802462 of the same category.

During the pre-licensing inspection, LPA did not observe items which do not comply with applicable laws and regulations.

Tele-inspection was completed and an exit interview was conducted. Copy of this report was emailed to the applicant. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to their application.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz LongTELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2021
LIC809 (FAS) - (06/04)
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