565802462-10-26-2022-29-AS-DPEA-CNKQMJ-20230130111736

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802462
Report Date: 10/26/2022
Date Signed: 10/26/2022 03:29:06 PM

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
07/10/2020 and conducted by Evaluator Kelly Dulek

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20200710125947

FACILITY NAME:	SAGE MOUNTAIN SENIOR LIVING		FACILITY NUMBER:	565802462
ADMINISTRATOR:	JADE ALMA-HARRIS		FACILITY TYPE:	740
ADDRESS:	3499 GRANDE VISTA DR		TELEPHONE:	(805) 375-0695
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91320
CAPACITY:	145	CENSUS: 96	DATE:	10/26/2022
		UNANNOUNCED	TIME BEGAN:	01:44 PM
MET WITH:	Jill Ford, Executive Director		TIME COMPLETED:	03:27 PM

ALLEGATION(S):

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Resident passed away due to lack of care and supervision

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced subsequent complaint investigation with the purpose of delivering findings for the allegation listed above. LPA met with Executive Director Jill Ford and discussed the reason for today’s visit. Entrance interview conducted.

Previously, LPA Dulek conducted an initial complaint inspection on 07/13/2020 telephonically with facility Designee Jade Alma-Harris. During that visit, LPA Dulek conducted a telephone interview with the facility Designee at 02:47PM and the LPA requested documents pertinent to the investigation. Throughout the course of the investigation, LPA Dulek interviewed Resident #1 (R1)’s family members and conducted interviews with facility staff. Additionally, Community Care Licensing (CCL) Program Clinical Consultant (PCC) conducted a medical record review for R1, which was completed on 09/22/2022. 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: 10/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

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-20200710125947

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: 10/26/2022

NARRATIVE

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Continued from LIC 9099-C
Record review revealed that R1 moved into the facility on 02/28/2020. R1’s physician’s report dated 02/21/2020 indicated R1’s diagnoses included hyperlipidemia, diabetes type 2, major depressive disorder, and atherosclerotic heart disease. Interview with family members revealed that prior to admittance to the facility, R1 had been diagnosed with stage 1 kidney failure. R1’s care plan dated 02/16/2020 indicates diabetic alerts, fall risk, vitals/weights monthly – every 1^st Wednesday. While residing at the facility, R1 had fallen on at least 4 dates in June 2020. Record review revealed R1’s physician was only notified of 2 out of the 4 total falls. And although R1’s physician’s orders state to “check fasting glucose levels daily. Please fax monthly report to (Primary Care Physician - PCP),” the facility did not fax record of blood glucose levels to R1’s PCP until after R1 was hospitalized on 06/23/2020. R1’s physician’s report dated 02/21/2020 indicated R1 weighed 189 pounds. Weight check conducted on 05/01/2020 revealed a weight loss of 24 pounds, as R1 weighed 165 pounds at that time. Record review revealed R1’s physician was not notified of this unplanned weight loss.

Review of R1’s daily blood sugar document revealed that R1 had episodes of hypoglycemia on 03/25/2020, 06/07/2020, 06/10/2020, 06/12/2020, 06/14/2020, 06/20/2020, 06/21/2020, and 06/22/2020. Progress notes indicate R1 did not have breakfast, lunch or dinner on 06/22/2020 and was hypoglycemic on this date. However, 2 medications ordered to be given with food were still administered. Blood glucose check performed by the facility Licensed Vocational Nurse (LVN) on 06/23/2020 at 07:00AM, indicated his blood glucose level was 23. Progress note indicated R1 was then given ½ cup of orange juice at 07:36AM. Another blood glucose check was performed at 08:16AM and measured even lower at 21. An additional ½ cup of orange juice was given to R1. As per niddk.nih.gov, orange juice is not to be given when one is having hypoglycemia for people with kidney disease, due to its high potassium content. Medication Administration Record (MAR) reviewed indicated both glimepiride and metformin scheduled at 09:00AM were given as well. At 10:51AM, R1 was transported via ambulance to the emergency department due to hypoglycemia. Emergency Department physician notes indicated R1 reported decreased consumption over the last several days. Additional hospital records reviewed indicated on 06/23/2020, R1’s labs were drawn and that R1 had both elevated potassium and creatine levels. That day, R1 was admitted to the hospital with diagnoses including “persistent hypoglycemia likely secondary to AKI (acute kidney injury) with oral antiDM (anti-diabetes mellitus) meds,” hyperkalemia (high potassium level in the blood), and dehydration.

Report Continued on LIC 9099-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20200710125947

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: 10/26/2022

NARRATIVE

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Continued from LIC 9099-C

R1 remained hospitalized until R1 passed away on 07/03/2020. Death certificate review indicated R1’s immediate cause of death was listed as cardiopulmonary arrest, with additional conditions leading to the cause of death that initiated the events resulting in death are listed as acute respiratory failure, non st elevation myocardial infarction, and coronary artery disease. Other significant conditions contributing to death were listed as chronic kidney disease, chronic obstructive pulmonary disease, diabetes mellitus type II.

Medical attention/intervention should have been extended by notifying R1’s physician for the occurrences as outlined above: unplanned weight loss, decrease in oral consumption, and incidents of hypoglycemia. The facility’s failure to notify or seek guidance from a qualified health professional for R1’s change in condition and failure to follow physician’s orders, contributed to R1’s hypoglycemia, dehydration, and acute kidney injury that necessitated R1’s hospitalization. However, there is no concrete medical evidence that can directly connect the delay of medical intervention as the cause or contributory factor to the resident’s death. Therefore, based on record review and interview, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred; as thus, the allegation "resident passed away due to lack of care and supervision" is deemed UNSUBSTANTIATED at this time.

No citations were issued. Exit interview was conducted with Executive Director Jill Ford. A copy of the report was provided via email.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

LIC9099 (FAS) - (06/04)

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