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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210109400
Report Date: 06/27/2023
Date Signed: 06/27/2023 12:13:53 PM

Document Has Been Signed on 06/27/2023 12:13 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:SAGE HOUSEFACILITY NUMBER:
210109400
ADMINISTRATOR:ANDREA JACKSONFACILITY TYPE:
735
ADDRESS:1 SAGE COURTTELEPHONE:
(415) 898-4239
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY: 6CENSUS: 6DATE:
06/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Andrea Jackson, AdministratorTIME COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Hansen conducted an unannounced annual 1 year required inspection to this facility and was welcome by staff Dominique Mills. Administrator Andrea Jackson was contacted by staff and arrived during the visit. Three clients had already left and three were leaving to attend day program at the time of the visit. There are 6 clients at the facility.

LPA toured the facility on 6/27/2023 at 8:15 AM with staff Dominique Mills; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on 5/23/2023 at the time of the visit. Smoke detectors and carbon monoxide detectors were found to be operational during the visit. Hot water temperature measured between 105.1 & 111.2 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 3 of 3 client’s bathroom faucets while touring facility on 6/27/2023. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked closed in the hallway and in the office. Dangerous items were stored inaccessible to develop disabled clients on 6/27/2023 while touring the facility with staff Dominique Mills. There was a supply of cleaners, hygiene products and paper products available for clients. The bathroom designated for clients at the facility were supplied with individual paper towels; hand soap dispenser was available. All six client’s bedrooms have lighting & appropriate furnishings, and beds were outfitted with mattress pads as required by Title 22 Regulations # 85088(c)(4).

A review of six clients and sample review of five staff records as well as two client’s medications was conducted. LPA reviewed client’s files at 9:15 AM on 6/27/2023 and learned that 6 of 6 clients have an updated reappraisal/needs & care plan, and physician’s report on file at this time as required by Title 22 Regulation.



Continue LIC 809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2023
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SAGE HOUSE
FACILITY NUMBER: 210109400
VISIT DATE: 06/27/2023
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Personal Rights for 6 of 6 clients were signed and on file on 6/27/2023. P&I's are kept in a locked filing cabinet in facility office room; facility responsible for all client’s P&I and money; facility had P& I and ledgers available during the visit. P& I money are not comingled and ledgers are current at this time.

Medications were centrally stored in a locked cabinet in the facility office by the kitchen. LPA conducted a review of medications for two clients. The Medications of 2 of 2 clients were found to be given according to physicians’ directions on 6/27/2023 at 10:30 AM. Centrally Stored Medication Records (CSMR) on 6/27/2023 at 10:30 AM were accurate for both clients in the facility.



LPA conducted a sample review of staff records at 9:45 PM on 6/27/2023 and learned that all staff present at the facility and other individuals who require caregiver background checks have received criminal record clearances or exemptions. In addition, Direct care staff have received training. LPA was presented with proof of CPR & 1st Aid certification for staff records that were reviewed. Andrea Jackson Administrator Certificate # 6020331735 has applied for renewal and LPA provided proof of pending. Facility will submit proof of valid Administrator Certificate for Andrea Jackson due to no internet connection.(LIC 9102 Advisory Notes)

LPA reviewed Licensing Information System (LIS) with Program Director who stated that is corrected and updated at this time. Disaster Drills are conducted monthly; last dated 6/13/2023.



There were no deficiencies cited at this time.
LPA is requesting the following updated documents be submitted to CCL by 7/16/2023:

LIC 308 Designated
LIC 500 Personnel Summary
LIC 400 Affidavit Regarding Resident Cash Resources
LIC 402 Surety Bond (if applicable)
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s
Copy of Control of Property/Grant Deed of Trust/Lease of Property
Copy of Administrator Certificate
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2023
LIC809 (FAS) - (06/04)
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