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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426471
Report Date: 10/04/2022
Date Signed: 10/04/2022 03:23:56 PM

Document Has Been Signed on 10/04/2022 03:23 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SAGEWOOD HOUSEFACILITY NUMBER:
336426471
ADMINISTRATOR:PIERCE, LISAFACILITY TYPE:
735
ADDRESS:41183 MAXWELL CT.TELEPHONE:
(442) 400-5577
CITY:INDIOSTATE: CAZIP CODE:
92203
CAPACITY: 6CENSUS: 4DATE:
10/04/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:42 PM
MET WITH:Lisa Pierce, LicenseeTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Jesse Gardner made an unannounced visit to conduct a case management visit to follow up on information regarding a resident death. LPA met with Licensee Lisa Pierce and explained the purpose of today's visit.

During the visit, LPA toured the facility and LPA interviewed Pierce for further information in regards to the death of R1 and the events that led up to R1's death.

LPA inquired about the cause of the death. A death certificate has not been issued at this time. Additionally, the preliminary cause of death is still being determined. LPA advised to send a copy of the death certificate to the regional office once received. R1's medications were reviewed, and R1 was found to have had all of their medication.

No deficiencies were cited during this visit, or health and safety concerns were observed.

An exit interview was conducted and a copy of this report was discussed with and provided to Pierce along with a copy of the LIC811.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2022
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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