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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202871
Report Date: 09/19/2022
Date Signed: 09/19/2022 09:49:21 AM

Document Has Been Signed on 09/19/2022 09:49 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:SAGEWELL HOMEFACILITY NUMBER:
435202871
ADMINISTRATOR:TRAN, ANTHONYFACILITY TYPE:
735
ADDRESS:5716 SAGEWELL WAYTELEPHONE:
(650) 868-2860
CITY:SAN JOSESTATE: CAZIP CODE:
95138
CAPACITY: 4CENSUS: 0DATE:
09/19/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Anthony TranTIME COMPLETED:
09:55 AM
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Licensing Program Analyst (LPA) Christine Dolores arrived announced to conduct the facility's pre-licensing inspection. LPA met with Licensees Anthony Tran and Thuy Tran.

There are no clients in care. LPA toured the facility to include 4 bedrooms, 2 bathrooms, living room, kitchen, and backyard. Fire exit routes are free and clear of obstruction. Fire clearance is approved for 4 ambulatory residents.

Facility has a designated entry point to include symptom screening and temperature check. Bedrooms observed supplied with furniture to include a bed, dresser, night stands, lights, and linens. LPA observed additional clean linens and towels. Facility has kitchen supplies to include eating utensils, plates, bowls, and cooking supplies. Medication cabinet observed to be locked. Trash cans observed with lid. First aid kit supplied with tweezers, scissors, bandages, and gauze. Hot water water temperature maintained at 113.7 degrees Fahrenheit. Facility has at least a 7 days worth of non-perishables. LPA observed facility's carbon monoxide detector. The following posters observed to include personal rights and grievance policy.

Component III is being waived because applicant has been a facility administrator since February 2020.

No issues noted during this pre-licensing inspection.

LPA observed the facility is ready to be licensed. However, this report will be submitted to the Central Application Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.

This report was reviewed with Licensees, Anthony Tran and Thuy Tran and a copy of this report provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2022
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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