Sage Care 2

Type of visit: Required - 1 Year

On 10/30/2023, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an annual inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator, Merilyn Bergstrom. LPA conducted a tour inside and outside of facility. Facility observed to be clean, odor free and at a comfortable temperature. Common areas were furnished well with adequate seating and lighting available. Resident rooms appeared clean and had required furnishings. Resident bathrooms were properly equipped with securely fastened grab bars in toilet and shower areas, non-skid mats were observed. Hot water measured between 106.5 degrees F and 114.7 degrees F. Kitchen toured, appeared clean. LPA observed a 7-day supply of non-perishable and 2-day supply of perishable food. Exterior tour conducted, all exits open and free of obstructions. Side gate was observed to be self-latching. Fire extinguisher serviced on 10/24/2023. Smoke detectors and carbon monoxide detectors observed operational during today’s inspection. Last fire drill conducted on 10/19/2023. LPA reviewed staff and client records. Medications reviewed and observed to have original labels and be administered as prescribed. First Aid Kit contained the required supplies. No deficiencies issued during today's inspection. Exit interview conducted. A copy of this report was discussed and provided to the Administrator, Merilyn Bergstrom, whose signature on this form confirms receipt of this document. LPA is requesting the following documents be submitted to the Fresno CCL office by 11/13/2023: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E), Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A), Surety Bondthe state’s words, verbatim · CDSS document, Oct 30, 2023

Type of visit: Post Licensing

On 08/04/2023, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct a Post-Licensing Inspection. LPA introduced self, stated that purpose of the visit and was allowed to enter the facility. LPA met with Administrator, Merilyn Bergstrom. LPA conducted a tour inside and outside the facility. LPA observed the following: Facility currently has 6 residents. Facility observed to be clean, odor free, and at a comfortable temperature. The dining room and living room were furnished well with adequate seating and lighting. Resident rooms appeared clean and had all required furnishings. LPA observed an adequate supply of linen. Resident bathrooms were properly equipped with securely fastened grab bars and non-skid mats. Hot water measured at 116 degrees F in the shared bedroom and 115.5 degrees F in the hallway bathroom. Kitchen toured, appeared clean, observed a 7-day supply of non-perishable and 2-day supply of perishable food. Knives/Sharps observed to be locked and inaccessible. Exterior tour conducted, all exits open and free of obstructions. Side gate was observed to be self-latching. Smoke detectors and carbon monoxide detectors observed operational during today’s inspection. Last fire drill conducted on 07/18/2023. All chemicals observed to be locked and secure. Medications observed to be locked in a closet and administered as prescribed. No deficiencies issued during today's visit. Exit interview conducted. A copy of this report was discussed and provided to Administrator, Merilyn Bergstrom, whose signature on this form confirms receipt of this document.the state’s words, verbatim · CDSS document, Aug 4, 2023

Type of visit: Prelicensing

On 11/15/2022, Licensing Program Analyst (LPA) A. Walton conducted an announced Pre-Licensing / Component III inspection. LPA Walton introduced self, stated purpose of visit, and was allowed entry into the facility. LPA met with Administrator, Merilyn Bergstrom. Facility has one central entry and exit. LPA observed a visitor log / temperature check upon entry. The facility is a 4 Bedroom and 3 Bathroom home and fire clearance was granted for 6 Non-Ambulatory for a total capacity of 6. LPA toured the facility with Administrator. Common areas were furnished and had adequate seating and lighting available. Bedrooms had required furnishings and are ready for occupancy. Hot water measured at 109.6 degrees F in bathroom 1 and 112.3 in the bathroom in the shared room. LPA observed an extra supply of bed linens and personal hygiene products. Kitchen was toured and observed to have dishes, plates, and utensils. Cleaning supplies and chemicals were observed in a locked cabinet in the garage. Medications are locked in a closet in the office. First aid kit was observed and contained all required items. A fire extinguisher was observed and has a service date of 07/1/2022. Smoke detectors and carbon monoxide were observed to be operational. Outside of facility toured. Exits were open and free of obstructions. LPA observed side gate to be self-latching. Component III was conducted during today’s pre-licensing visit. I have found that the applicant has met all pre-licensing requirements. LPA will submit documentation to CAB in Sacramento for final review prior to license being issued.the state’s words, verbatim · CDSS document, Nov 15, 2022

Type of visit: Office

Facility Type: RCFE Application Type: CHOW Capacity: 6 Census (if any clients in care): 6 COMP II Participants: Merilyn Bergstrom(Applicant/Administrator) Interview Method: Telephone interview with CAB Applicant/Administrator participated in COMP II. During COMP II, Applicant/ Administrator confirmed the understanding of the California Code Title 22 Regulations. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Applicant and Administrator qualifications 3. Staff Qualifications - hiring procedures, responsibilities; training 4. Program policies -restricted/prohibited health conditions, medication management; incident reporting to CCLD; food service and management, Activities program 5. Grievances, Complaints, Community resources; Abuse reporting 6. Application document review and technical assistance- Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator Certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of propertythe state’s words, verbatim · CDSS document, Oct 26, 2022