565802462-9-9-2021-29-AS-KHEN-C79VSG-20210927164132

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802462
Report Date: 09/09/2021
Date Signed: 09/09/2021 02:44:01 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/13/2021 and conducted by Evaluator Kelly Dulek

COMPLAINT CONTROL NUMBER: 29-AS-20210413145029

FACILITY NAME:	SAGE MOUNTAIN SENIOR LIVING		FACILITY NUMBER:	565802462
ADMINISTRATOR:	MARTHA BERARD		FACILITY TYPE:	740
ADDRESS:	3499 GRANDE VISTA DR		TELEPHONE:	(805) 375-0695
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91320
CAPACITY:	145	CENSUS: 78	DATE:	09/09/2021
		UNANNOUNCED	TIME BEGAN:	10:54 AM
MET WITH:	Jill Ford & Tammy Doss		TIME COMPLETED:	01:35 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff is not allowing the LTCO to have confidential meetings with residents

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint investigation with the purpose of delivering findings for the allegations listed above at 10:54 AM. LPA Dulek met with facility Administrator Jill Ford and Regional Director of Operations Tammy Doss and discussed the reason for today's visit. Entrance interview conducted.

During today's visit, LPA conducted a facility tour at 12:02PM with Sales and Marketing Director Melissa Saldibar and gathered copies of pertinent documents. During an initial complaint investigation on 4/20/2021, LPAs Dulek and Emily Peraldi interviewed Administrator Martha Berard at 11:25AM and conducted staff interviews from 11:52AM - 12:10PM and again at 12:35PM. LPAs Dulek and Peraldi, along with facility staff Annabelle Amaya conducted a facilty tour at 12:14PM. LPAs also obtained copies of staff schedule, resident roster, visitor logs and other pertinent documentation relevant to the investigation.

Report Continued on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 29-AS-20210413145029

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SAGE MOUNTAIN SENIOR LIVING	FACILITY NUMBER: 565802462
	VISIT DATE: 09/09/2021

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
26
27
28
29
30
31
32

Continued from LIC 9099

Additionally, LPA Dulek conducted interviews with other relevant parties telephonically on 4/21/2021 and 4/22/2021. The following was then determined:

Record review revealed that LTCO representatives had visited at the facility on 4/9/2021. There were two LTCO representatives signed in on that day. Interviews revealed that the LTCO representatives were not escorted throughout the facility and were allowed to move freely and visit whomever they chose. One LTCO representative went inside a resident room and remained there the entirety of their visit. One LTCO representative walked around the facility and it was the LTCO representative who chose not to meet privately with any residents during that visit. Based on all information gathered, the Department does not have sufficient evidence to prove the complaint allegation. Therefore, the above allegation “Facility staff is not allowing the LTCO to have confidential meetings with residents” is deemed UNSUBSTANATIED at this time.

Exit interview conducted. No citations issued. A copy of this report was provided to the Administrator via email.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 2