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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202871
Report Date: 07/27/2024
Date Signed: 07/27/2024 09:51:13 AM

Document Has Been Signed on 07/27/2024 09:51 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/
DIRECTOR:		TRAN, ANTHONYFACILITY TYPE:
735
ADDRESS:5716 SAGEWELL WAYTELEPHONE:
(650) 868-2860
CITY:SAN JOSESTATE: CAZIP CODE:
95138
CAPACITY: 4CENSUS: 4DATE:
07/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:57 AM
MET WITH:Staff Brandon VuongTIME VISIT/
INSPECTION COMPLETED:
09:45 AM
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Staff (S1) Brandon Vuong. During the visit, LPA observed 3 residents and 2 staff. LPA explained the purpose of the visit. Staff S1 notified facility ADM regarding the unannounced annual inspection via text message.

LPA rang the facility door bell and entered the facility at 7:57am. LPA observed staff S1 and S2 sitting on the couch. LPA reviewed LIS536, and staff S2 was not on the facility personnel Report summary. LPA searched S2's name in Guardian and S2 is fingerprinted but not associated to the facility. S2 stated he/she has been working at the facility since May 20, 2024. Facility ADM stated they have sent the transfer association forms to CCL. ADM stated he would associate S2 by the end of the day and send LPA confirmation.

LPA toured the facility inside out with S1 which included the Living room, kitchen, dining room, 2 restrooms and 4 residents bedrooms. The front yard and backyard were inspected. There was no obstruction to block the walkways.

Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 70 degrees F, and hot water temperature was measured at 114 degrees F in both resident bathrooms.

Fire extinguisher was serviced in April 26, 2024. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by S1, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on June 1, 2024.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2024
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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: SAGEWELL HOME
FACILITY NUMBER: 435202871
VISIT DATE: 07/27/2024
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LPA reviewed facility records for 2 staff and 2 residents. LPA reviewed 2 resident medications and centrally stored medication records. LPA conducted interviews with 1 staff and 1 resident.

No deficiencies cited during today's visit. This report was reviewed with Administrator Tran and a copy of the signed report was provided

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END OF REPORT.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2024
LIC809 (FAS) - (06/04)
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