565802462-10-14-2022-29-AS-KLOZ-CK7V62-20221014160849

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565802462
Report Date: 10/14/2022
Date Signed: 10/14/2022 04:10:13 PM

Document Has Been Signed on 10/14/2022 04:10 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	SAGE MOUNTAIN SENIOR LIVING		FACILITY NUMBER:	565802462
ADMINISTRATOR:	JILL FORD		FACILITY TYPE:	740
ADDRESS:	3499 GRANDE VISTA DR		TELEPHONE:	(805) 375-0695
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91320
CAPACITY:	145	CENSUS: 97	DATE:	10/14/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Jennifer Miller		TIME COMPLETED:	03:00 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	Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Required 1 Year inspection at the facility today. The LPA met with Jennifer Miller, Business Office Manager, at 10:41 AM and explained the reason for today's visit. Administrator Jill Ford was not available. Today's annual will also have an emphasis on infection control practices and procedures. The LPA, along with Jennifer Miller, 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 at the front desk for signs and symptoms of COVID-19. Furnishings in common areas were found to be in good repair. Signs regarding infection control are posted in the common areas and common bathrooms. The Community Care Licensing complaint filing information poster along with other required postings were observed by the resident mail boxes on the first floor. The smoke detectors and fire alarm system was last serviced on 09/26/2022 and passed inspection. Fire extinguishers observed were fully charged and last serviced on 07/08/2022. Medications are centrally stored in the medication rooms in the memory care unit and on the third floor in Assisted Living. An Evac-Chair was observed in the stairwell between the third and forth floor. Personal Protective Equipment supplies were observed in a storage room. Kitchen/Dining area: The LPA toured the kitchen, and kitchen storage areas with Anthony Aquino, 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. Cleaning supplies and chemicals are stored separately from the food. Report continued on LIC 809-C.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra Lopez	TELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022

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

LIC809 (FAS) - (06/04)

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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: 10/14/2022

NARRATIVE

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Resident Apartments: A random selection of six resident apartments in assisted living and four resident apartments in the memory care were observed between 11:04 AM and 1:00 PM. There are currently 64 assisted living residents and 23 memory care residents. The smoke detectors/carbon monoxide detectors and the hot water temperature was tested in apartments 109, 212, 257, 238, 244, 230, 222, 322, 343, and 403. The smoke/carbon monoxide detectors tested were operational. The hot water measured between 111.2 and 116.6 degrees F. Resident bathroom showers were observed to have grab bars and non-skid strips. Resident apartments were observed to be furnished appropriately. The signal system in Assisted Living was tested and is operational. The delayed egress doors in the outside patio of the memory care were tested and found to be operational. Although the alarm to alert staff audibly inside the memory care front desk/medication room area was not operational when the alarm was activated by Maintenance Director Jace Evans. The LPA observed the ipod which caregivers carrying to be alerted that the delay egress door alarm was activated.

File Review: LPA reviewed files for six memory care residents. Files had signed admission agreements and current medical assessments.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Business Office Manager Jennifer Miller and Maintenance Director Jace Evans 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) and the ability to obtain more if necessary. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room.

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

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra Lopez	TELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 10/14/2022 04:10 PM - It Cannot Be Edited

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: 10/14/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/18/2022 Section Cited	1 2 3 4 5 6 7	87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidence by:
	8 9 10 11 12 13 14	Based on observation, the licensee failed to comply with the section cited above, as the delayed egress auditory alarm located in the memory care front desk/medication room was not operational which poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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 Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra Lopez	TELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022

LIC809 (FAS) - (06/04)

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