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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426471
Report Date: 07/15/2024
Date Signed: 07/15/2024 11:41:41 AM

Document Has Been Signed on 07/15/2024 11:41 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SAGEWOOD HOUSEFACILITY NUMBER:
336426471
ADMINISTRATOR/
DIRECTOR:		PIERCE, LISAFACILITY TYPE:
735
ADDRESS:41183 MAXWELL CT.TELEPHONE:
(442) 400-5577
CITY:INDIOSTATE: CAZIP CODE:
92203
CAPACITY: 6CENSUS: 4DATE:
07/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:37 AM
MET WITH:Licensee and Administrator, Lisa PierceTIME VISIT/
INSPECTION COMPLETED:
11:46 AM
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Licensing Program Analyst (LPA) Seo Jeon and Janira Arreola conducted an unannounced annual required visit. LPA was granted entry and met with Licensee and Administrator, Lisa Pierce, who was informed of the purpose of the visit. At the time of the visit there were one (1) staffs and zero (0) clients present.

The facility is a single story home with 4 bedrooms and 2 bathrooms with attached garage. There are no pools or other bodies of water located on the premises and no firearms or other dangerous weapons are stored at the facility. The clients served are adults between the ages of 18-59. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted staff interviews. LPA observed the following:

Infection Control: The LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements. LPA reviewed staff records and found that all staff had infection control training.



Physical Plant: LPA observed the client bedrooms and staff office. Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards. LPA observed outdoor furniture and shaded area for clients. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to clients. The smoke and carbon monoxide detectors were operational, and the hot water temperature was 105.4 F.

Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE: DATE: 07/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/15/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SAGEWOOD HOUSE
FACILITY NUMBER: 336426471
VISIT DATE: 07/15/2024
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Care & Supervision/Administration: Adequate staff are present for the supervision of clients during the visit. LPA also reviewed the staff scheduled showing adequate staff coverage. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The listed administrator possesses a current administrator's certificate.

Record Review and Resident/Staff Files: LPA reviewed two(2) staff files and training. All staff have criminal clearance and updated training along with CPR/First Aid Certification. Two (2) client files were reviewed and possessed all required paperwork.



Health Related Services/ Incidental Medical Services: All client medication was locked in a cabinet located in the office area. LPA reviewed medications for two (2) clients and found all medication listed on MARs and all required labeling was found to be in place.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing the facility performs monthly fire and earthquake drills, which met the department requirements. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies in the garage and first aid kit with all required items.

No deficiencies were cited per Title 22, Division 6 of the California Code of Regulations at this time.

An exit interview was conducted where a copy of this report was provided to Lisa Pierce, administrator.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2024
LIC809 (FAS) - (06/04)
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