<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603413
Report Date: 04/08/2024
Date Signed: 04/08/2024 05:11:23 PM


Document Has Been Signed on 04/08/2024 05:11 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:SAGE GLENDALE SENIOR LIVINGFACILITY NUMBER:
198603413
ADMINISTRATOR:SMITH,ANGELAFACILITY TYPE:
740
ADDRESS:525 W ELK AVETELEPHONE:
(818) 245-6378
CITY:GLENDALESTATE: CAZIP CODE:
91204
CAPACITY:113CENSUS: 63DATE:
04/08/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:04 PM
MET WITH:Mary Lou Dominguez, LVNTIME COMPLETED:
05:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
An unannounced Case Management Incident visit was conducted on this day by Licensing Program Analyst (LPA) Rosaura Valenzuela. The purpose of this visit is to follow-up on an incident report that was submitted to Licensing on 4/04/24 regarding Resident #1 (R1). LPA met with LVN Mary Lou Dominguez and explained the reason for the visit.

It was reported that on 3/31/2019 at approximately 3:21 pm staff received a call from R1's spouse indicating that R1 had overdosed on prescribed medication. 911 was called and R1 was transported to the hospital.

On 4/08/2014, LPA Valenzuela spoke to LVN Mary Lou Dominguez. Interview revealed that R1 is still at the hospital. Facility is awaiting the discharge orders and to conduct a reappraisal before accepting R1 back to the community.

LPA requested and reviewed the following documents: R1's physician report, medication list, pre-appraisal, and medication orders from the physician. Records revealed that R1 is depressed. R1 does have approval from their doctor to self-administer their own medication. Facility contacted the hospital and asked what the laboratory results were. Hospital staff indicated that blood work was unremarkable. Apparently R1 did not ingest the medication that was reported to have been taken.

No health and safety issues noted.

Exit interview conducted and a copy of the report was issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: 818-596-4334
LICENSING EVALUATOR SIGNATURE:
DATE: 04/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1