565802462-10-14-2022-29-AS-KLOZ-CK7VBA-20221014161713

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565802462
Report Date: 10/14/2022
Date Signed: 10/14/2022 04:19:35 PM

Document Has Been Signed on 10/14/2022 04:19 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:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Nicolle Hozner		TIME COMPLETED:	03:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) KaSandra Lopez initiated a Case Management - Incident visit. The purpose of this visit is to conclude an investigation initiated by LPA Lopez during a Case Management – Incident visit conducted on 06/10/2022. During today’s visit LPA Lopez met with Director of Health And Wellness Nicolle Hozner. Administrator Jill Ford was not available for today's visit. Entrance interview conducted.

On 05/28/2022, Community Care Licensing Division (CCLD) received a faxed death report pertaining to Resident#1 (R1) who passed away on 05/28/2022. R1 was receiving hospice care services at the time of death and was admitted under hospice with a diagnosis of Intracranial Hemorrhage. At the time the death report was received, the last reported fall to CCLD R1 had was on 03/11/2022 when another resident pushed R1 and no injuries were sustained.

On 06/10/2022, LPA Lopez conducted an unannounced Case Management inspection at the facility. During the inspection, the LPA reviewed facility records, obtained copies of pertinent records, and discussed R1's history with the Administrator Jill Ford and Director of Health and Wellness Nicolle Hozner, between 11:10 AM and approximately 2:00 PM. Record review revealed, internal Resident Incident Reports dated 04/18/2022 and 04/20/2022 state the resident had unwitnessed falls resulting in a bump on their head with fresh blood requiring emergency medical treatment at the hospital for the fall and head injury. R1 was then admitted under hospice care on 04/29/2022 with a diagnosis of Intracranial Hemorrhage. R1 also had an unwitnessed fall on 05/06/2022 and complained of leg pain. R1’s family took R1 to the hospital for this fall. During the interview with the Administrator, she stated hospice gave the diagnosis of Intracranial hemorrhage due to a history of falls and was not related to a particular fall. Interviews with the Administrator and Ms. Hozner also revealed, the fall incidents were not reported to CCLD, as Ms. Hozner was mistakenly under the impression from her prior employer, that CCLD did not need to be notified if a resident returned to the facility from the hospital within 24 hours.

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

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The LPA determined further investigation was needed and CCLD’s Investigation’s Branch (IB) Investigator Peter Zertuche was assigned to complete the investigation. Investigator Zertuche reviewed facility records, and reviewed subpoenaed records from Los Robles Medical Center, Livingston Memorial Hospice, and the Ventura County Recorder’s office. Investigator Zertuche also conducted telephone interviews with Witness #1, (W1) on 08/16/2022, Family member of R1, Staff #1 (S1) and Resident #2 (R2) on 08/18/2022, Staff #2 (S2) on 08/22/2022, and Witness #2 (W2) on 08/29/2022. Interviews and record review revealed R1 had a history of falls and a diagnosis of Intracranial Hemorrhage. However, according to W2, the cause of the Intracranial Hemorrhage was unknown and could have been caused by a stroke. W2 also reported no neglect or anything suspicious of R1’s death. The interviews with the family member and W1 also revealed no issues or concerns of neglect related to R1’s death. Additionally, interviews conducted revealed R1 did not need one to one care. A review of the Certificate of Death lists the cause of death as End Stage Ischemic Cerebrovascular Disease.

Based on the information obtained, there were no deficiencies related to R1’s death at this time. However, a deficiency will be cited for the facility failing to report R1’s multiple falls to CCLD.

The following deficiency was observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Exit interview and report reviewed with the Ms. Hozner. A copy of the report and appeal rights will be 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)

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Document Has Been Signed on 10/14/2022 04:19 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 10/21/2022 Section Cited	1 2 3 4 5 6 7	87211 Reporting Requirements a) Each licensee shall furnish to the licensing agency such reports as the Department may require, ... D)Any incident which threatens the welfare, safety or health of any resident, such as.... This requirement is not met as evidenced by:
	8 9 10 11 12 13 14	Based on record review and interview, the licensee failed to comply with the section cited above, as the facility did not submit written incident reports to CCLD pertaining to Resident #1 (R1) which poses a potential personal rights 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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