<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210109400
Report Date: 06/11/2024
Date Signed: 06/11/2024 02:58:51 PM

Document Has Been Signed on 06/11/2024 02:58 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:SAGE HOUSEFACILITY NUMBER:
210109400
ADMINISTRATOR/
DIRECTOR:		YVETTE MORGANFACILITY TYPE:
735
ADDRESS:1 SAGE COURTTELEPHONE:
(415) 898-4239
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY: 6CENSUS: 6DATE:
06/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Administrator, Yvette MorganTIME VISIT/
INSPECTION COMPLETED:
03:20 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPA) Helena Rummonds and Jacky Macias arrived unannounced at approximately 9:00AM to conduct an Annual Required inspection and was greeted by staff. LPAs and staff discussed the purpose of the visit. Administrator, Yvette Morgan arrived shortly after.

LPAs and Administrator initiated a tour of the facility around 09:35 AM and made the following observations: Facility was at a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in sinks accessible to clients measured at 113, 114, and 115 degrees F which is within the range of 105 to 120 degrees F allowed per regulation.

Extra hygiene products and linens were available. LPAs observed bleach, lysol, and other various hygiene supplies in the unlocked garage (deficiency cited, see 809D). Laundry detergent was observed in a cabinet equipped with an unsecured padlock. Facility has at least two days of perishable and one week of non-perishable foods which were of quality and stored per regulation. Medications were centrally stored and locked. Emergency food and water is stored in the garage. Personal Protective Equipment is stored in the garage.

Fire extinguishers were last serviced 4/25/2024. Facility smoke and carbon monoxide detectors located throughout the facility were tested and operational during inspection. Most recent fire/disaster drill was conducted 03/13/2024. Five staff files and five resident files were reviewed. S1 does not have a Health Screen on file. Staff have required First Aid and CPR certificates. Medications and medication records were reviewed. Centrally Stored Medication List is currently not updated (deficiency cited, see 809D).

Continued on LIC809C
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE: DATE: 06/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/11/2024
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 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SAGE HOUSE
FACILITY NUMBER: 210109400
VISIT DATE: 06/11/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from LIC809

Administrator agrees to audit the Centrally Stored Medication List and update all medications.Client cash resources were reviewed and cash counted did not match the amount depicted in Record of Cash Resources (LIC405) (deficiency cited, see 809D). Administrator Certificate for Administrator, Yvette Morgan (6066968735) is up to date and expires 07/19/2025.

Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on forms confirms receipt of documents.

LPA is requesting the following documents to be submitted to Community Care Licensing by 07/11/2024:

LIC 500 Personnel Report
LIC 9020 Client Roster
LIC 308 Designation of facility responsibility
Surety Bond
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024
LIC809 (FAS) - (06/04)
Page: 6 of 6
Document Has Been Signed on 06/11/2024 02:58 PM - It Cannot Be Edited


Created By: Helena Rummonds On 06/11/2024 at 02:03 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: SAGE HOUSE
FACILITY NUMBER: 210109400

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in that LPAs observed bleach, lysol, and other various hygiene supplies in the unlocked garage which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/12/2024
Plan of Correction
1
2
3
4
Administrator immediately removed bleach from unlocked garage. Administator agrees to submit a plan addressing how they will ensure that backstock of toxic chemicals will remain inaccessible to clients in care to LPA by POC due date of 06/12/2024.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Victoria Bertozzi
LICENSING EVALUATOR NAME:Helena Rummonds
LICENSING EVALUATOR SIGNATURE:
DATE: 06/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2024


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 06/11/2024 02:58 PM - It Cannot Be Edited


Created By: Helena Rummonds On 06/11/2024 at 02:03 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: SAGE HOUSE
FACILITY NUMBER: 210109400

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80026(h)
Safeguards for Cash Resources, Personal Property and Valuables
(h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in that monies were not accurate in P&I book and did not have clients signatures acknowledging that they received the cash which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/25/2024
Plan of Correction
1
2
3
4
Administrator agrees to audit the P&I Log book to identify discrepencies. Administrator agrees to review the Title 22 Regulation: 80026 -Safeguards for Cash Resources, Personal Property, and Valuables of Residents to create a new plan on money management which include procedures outlined in the regulation. Updated procedures to be submitted to LPA by POC due date of 6/25/2024.
Type B
Section Cited
CCR
80075(k)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in that Centrally Stored Medication List is not updated to current medications which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/25/2024
Plan of Correction
1
2
3
4
Administrator agrees to audit the Centrally Stored Medication List and corresponding medications to ensure that they are accurate. Adminstrator agrees to submit a plan addressing how to avoid record keeping errors in the future to LPA by POC due date of 6/25/2024.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Victoria Bertozzi
LICENSING EVALUATOR NAME:Helena Rummonds
LICENSING EVALUATOR SIGNATURE:
DATE: 06/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6