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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210109400
Report Date: 12/12/2024
Date Signed: 12/12/2024 03:02:05 PM

Document Has Been Signed on 12/12/2024 03:02 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
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:
12/12/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:20 PM
MET WITH:Program Manager, Tracey DavisTIME VISIT/
INSPECTION COMPLETED:
03:10 PM
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At approximately 2:20PM, Licensing Program Analysts (LPA) Loera arrived unannounced to conduct a Case Management - Incident Visit and met with Program Manager, Tracey Davis. The purpose of the visit was to follow up on self-reported incident that were submitted to Community Care Licensing (CCL).

Incident Report: CCL received an incident report on 11/1/2024. Report stated that on 10/28/2024, at approximately 9 am while Client (C1) was being assisted in the shower, C1 reached for the handle and slipped on the floor. As a result to the fall, C1 had a laceration on the left side of the head behind his ear. C1 then had another fall around 9:30am, while standing in the kitchen, C1's body became rigid. Staff called 911 and C1 was taken to Kaiser and given a head CT + 4 staples to his laceration. C1 was then discharged at 2:30pm with needing a follow-up, head and neck surgery on 11/08/2024 at 10:00am.

Per conversation, Client did not get head and neck surgery. The follow up appointment on 11/08/2024 was to get the staples removed.

Facility made all appropriate notifications per regulation.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report and LIC811 (Confidential Names) discussed and provided to Program Manager.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2024
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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