565802462-9-16-2022-29-AS-KHEN-CJFRNZ-20220920131109

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802462
Report Date: 09/15/2022
Date Signed: 09/16/2022 09:06:58 AM

Unsubstantiated

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
02/19/2021 and conducted by Evaluator Kelly Dulek

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20210219171530

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: 93	DATE:	09/15/2022
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Jill Ford/Jennifer Miller		TIME COMPLETED:	05:32 PM

ALLEGATION(S):

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Licensee failed to meet resident's hygiene needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kelly Dulek initiated a subsequent complaint investigation for the allegation listed above. LPA arrived at 10:45AM and met with Executive Director Jill Ford. Entrance interview conducted.

During today’s visit, LPA interviewed Executive Director Jill Ford throughout the visit, reviewed pertinent records at 11:00AM, toured the facility with Health and Wellness Director at 02:15PM, and conducted interviews between 02:22PM and 03:55PM. Previously, during an initial complaint inspection on 02/26/2021 conducted virtually, LPA Dulek conducted a telephone interview with the administrator at 04:20PM, a virtual tour at 04:33PM. During a subsequent complaint inspection conducted on 09/09/2021, LPA Dulek conducted a facility tour at 12:02PM with Sales and Marketing Director Melissa Saldibar and gathered copies of pertinent documents. The following was then determined:
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: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

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

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20210219171530

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: 09/15/2022

NARRATIVE

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It was alleged that Resident #1 (R1) developed a severe infection while in care. R1’s records were reviewed throughout the investigation. Record review revealed that R1’s care plan dated 12/01/2020 indicated R1 “does not require assistance with daily grooming, but staff will need to confirm (R1) is washing (R1’s) hands, face, and brushing (their) teeth. (R1) wears partial dentures that (they) need to soak at night and put on in AMs.” Care notes indicate that R1 was checked daily and had no concerns noted regarding hygiene. R1 was diagnosed with a tooth abscess while R1 was hospitalized for an unrelated event. R1 was then prescribed antibiotics for the infection and scheduled for a follow up appointment with the dentist a week later. R1’s antibiotics were administered daily at the facility, as prescribed. Interview revealed that R1 was very independent and was compliant with meeting hygiene needs. Although it is not necessary, interview revealed that most staff will stay with a resident to ensure they complete tasks, even if they are only on reminders to ensure resident needs are met. If a resident does not require assistance with brushing teeth, the staff would not have been observing that resident's teeth on a daily basis, especially during this time period, as residents were required to wear masks and socially distance. Based on interview and record review, although the allegation may be valid, at this time there is insufficient evidence to prove a violation did occur, therefore the allegation that “resident developed a severe infection while in care” is deemed UNSUBSTANTIATED at this time.

No deficiencies were cited. Exit interview conducted with Jennifer Miller, Business Office Manager. A copy of the 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: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

LIC9099 (FAS) - (06/04)

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