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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802462
Report Date: 11/22/2021
Date Signed: 11/22/2021 05:54:51 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 LIVINGFACILITY NUMBER:
565802462
ADMINISTRATOR:JILL FORDFACILITY TYPE:
740
ADDRESS:3499 GRANDE VISTA DRTELEPHONE:
(805) 375-0695
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91320
CAPACITY:145CENSUS: 90DATE:
11/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:24 PM
MET WITH:Hannah RobertsonTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Required 1 - Year inspection at the facility today. The LPA met with Business Office Manager Hannah Robertson at 12:28 PM and explained the reason for today's visit. Administrator Jill Ford was not available for today's visit.

Today's annual has an emphasis on infection control practices and procedures. The LPA, along with Hannah Robertson, and Maintenance Director Jace Evans conducted a physical plant tour of the inside and outside of the facility to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations and the Health and Safety Code.

Common areas - Upon entry into the facility, there is central screening station for signs and symptoms of COVID-19 and to record contact information. Signs regarding infection control are posted in the common areas and common bathrooms. The complaint poster and other required postings were observed by the resident mail boxes. The smoke detectors and fire system is serviced annually. Fire extinguishers observed were serviced within the last 12 months. Medications are centrally stored in the medication rooms in the memory care unit and on the third floor in Assisted Living.

Kitchen/Dining area: The LPA toured the kitchen, and kitchen storage areas with Christian Torres, Director of Culinary Services. The menu was posted. The freezers and refrigerators stored food at the appropriate temperatures. The facility has a sufficient supply of perishable and non-perishable food. Although, the facility did not have any bottled water or any other type of stored water for use in case of an emergency.

Resident Apartments: A random selection of 10 resident apartments were observed between 12:55 PM and 2:08 PM. The smoke detectors were tested in each room and were operational. The hot water temperature was tested in apartments 109, 104, 220, 259, 234, 248, 224, 309, 305, and 403 and measured between 114.8 and 120 degrees F. Report continued on LIC 809-C.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 11/22/2021
NARRATIVE
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Resident bathroom showers were observed to have grab bars and non-skid strips. Resident apartments were observed to be furnished appropriately. The signal system was tested and is operational. A tour of the memory care unit located on the second floor was conducted. During the tour at 1:34 PM, the LPA observed the laundry room to be unlocked. In the laundry room there was bleach and other cleaning supplies in an unlocked cabinet. The outside memory care patio was observed which is secured by delayed egress gates. The delayed egress gate was tested and found to be operational. During the inspection, it was observed that Staff #1 (S1) was not associated to the facility.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Business Office Manager Hannah Robertson regarding the facility’s infection control practices. There is 1 entry into the facility. Upon entry, the facility has a central entry point for symptom screening. The facility has at least a 30 day supply of Personal Protective Equipment (PPE). The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

The LPA requested an updated LIC 610E be submitted.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Civil penalties assessed. Failure to correct the deficiencies may result in civil penalties. Exit interview and report reviewed with Ms. Robertson. A copy of the report and appeal rights was emailed.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(2)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as one staff's criminal record clearance was not transferred to the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2021
Plan of Correction
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The licensee shall submit the request of transfer of criminal record clearance for Staff #1 (S1). A civil penalty is being assessed and will continue to accrue until the transfer request is submitted.
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as the laundry room with bleach and other cleaning supplies was unlocked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/03/2021
Plan of Correction
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The door was locked during the inspection. The administrator shall submit proof that staff who work in the memory care had an in-service training regarding regulation 87705 and submit proof to CCL by 12/03/2021.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(a)(2)
Other Provisions
(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above as the facility had no bottled water or any other emergency water which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/26/2021
Plan of Correction
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The Director of Culinary stated they will have 25 five gallon jugs of water by Wednesday and a case of water for each resident room. Proof shall be submitted by 11/26/2021 that the facility has enough water for all residents and staff to be no self-reliant for no less than 72 hours.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2021
LIC809 (FAS) - (06/04)
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