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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565802462
Report Date: 02/10/2023
Date Signed: 02/10/2023 11:42:19 AM

Substantiated


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
01/17/2023 and conducted by Evaluator Kasandra Lopez
COMPLAINT CONTROL NUMBER: 29-AS-20230117111024
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: 108DATE:
02/10/2023
UNANNOUNCEDTIME BEGAN:
09:54 AM
MET WITH:Jennifer Miller and Ian GadeaTIME COMPLETED:
11:50 AM
ALLEGATION(S):
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Staff drinks alcohol while on duty
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced subsequent complaint inspection to deliver the findings for the above allegation. The LPA met with Business Office Manager Jennifer Miller and Director of Health and Wellness Ian Gadea at 10:08 AM and explained the reason for the inspection. Administrator Jill Ford was unavailable today.

On 01/17/2023, Community Care Licensing Division (CCLD) received a complaint alleging 'Staff drank alcohol while on duty'. On 01/18/2023, LPA Lopez conducted an inspection at the facility initiating the investigation and conducted interviews with eight staff members in person and one staff member on the telephone, including Staff #1 (S1), Staff #2 (S2), and Staff #3 (S3) between approximately 10:50 AM and 1:15 PM. The LPA also conducted a physical plant tour with Ms. Miller and Mr. Gadea, including but not limited to the memory care, memory care kitchen, and memory care kitchen storage area. Records were also reviewed during the visit. Report continued on LIC 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 29-AS-20230117111024
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: 02/10/2023
NARRATIVE
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 On 01/18/2023, two additional staff members were also interviewed after the issuing of the report at the facility between approximately 3:56 PM and 4:19 PM. On 01/19/2023 and on 01/23/2023, the LPA conducted telephone interviews with three staff, including Staff #4 (S4). On 01/26/2023, the LPA conducted a subsequent inspection, and conducted additional interviews with S1 and S2 between 11:29 AM and 12:03 PM.

During the course of the investigation, LPA Lopez received photos that were posted on social media allegedly by S1. In the photos, four staff members identified as S1, S2, S3, and S4 and who were working in the memory care at the time. The staff members were all wearing blue tops and the photos were identified as being taken at the facility. On the social media post the words “WHEN ITS MY BDAY EVERYONES DRINKING LOL” were written. In the photos, one staff member is holding what appears to be a clear, wide glass bottle, although the label on the photo was unclear in the photo. In another photo, a staff member is seen drinking from this bottle.

The LPA also obtained a photo of the alleged bottle staff were drinking while at work. The bottle brand was "Gran Malo" and "Spicy Tamarindo" was written on the label. The rest of the wording was in Spanish. However, on the bottle it states "LICOR CON TEQUILA SABOR TAMARINDO. HECHE CON TEQUILA BLANCO. The alcohol content listed is 30% Alc. 750 ml. The bottle is a clear wide bottle with a white label and red writing and a silver screw on top. The person holding the bottle is wearing a blue top, has long dark nails and is holding the bottle over what looks to be a plastic container with food in it on a tan counter top with a tile floor.

During the initial telephone interview with S1, S1 confirmed on 01/13/2023 they made the post on their Instagram story of S1, S2, S3, and S4 while having a potluck birthday party for S1 while at work. S1 stated the potluck was during their lunch break at 11:30 AM during the AM shift in the memory care. S1 stated they made food for the potluck. When asked about the social media post, S1 stated they were only joking when they posted the quote “WHEN ITS MY BDAY EVERYONES DRINKING LOL”. S1 denied there being alcohol in the bottle being drank from in the photos and stated it was “Tamarind”, which was a “Mexican candy water”. S1 described the bottle as a white "Voss" like looking water bottle.

Report continued on LIC 9099-C.

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

DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20230117111024
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: 02/10/2023
NARRATIVE
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During the subsequent interview with S1 on 01/26/2023, the LPA showed S1 the picture of the Gran Malo alcoholic beverage taken in the memory care. S1 stated although they had long nails at the time of the party, they denied they were holding the bottle in the photo, stating the person in the photo had a different color polish than what they had at the time. S1 also denied this was the bottle S4 brought to the pot luck and in their social media post.

During the interviews with S2, they confirmed they were in the social media photos posted by S1. S2 was observed to have long nails but denied being the person holding the bottle of alcohol in the photo. S2 stated they could not recall what staff were drinking during the potluck and denied drinking any alcohol.

During the interview with S3, they confirmed they were the person who was drinking from the bottle in the photo on social media. Although, S3 denied they were drinking alcohol and stated they were drinking water.

During the interview with S4 they also denied drinking alcohol at work and stated what staff were drinking was “Tamarindo water”, which was described as a “Mexican sparkling water”. During the interview with S4, they confirmed they were the individual who brought the bottle to work for the potluck. S4 stated they also brought food to the party. S4 stated they had the bottle in their car. S4 stated the bottle was gift from their sister who purchased it in Mexico and stated it was Tamarindo sparkling water. S4 said it was clear like sparkling water and did not contain alcohol. LPA inquired if S4 knew the name of brand of the water they brought to the party but S4 said they were not sure and it was a Mexican brand

During the investigation, the LPA observed the memory care kitchen and storage area and was able to confirm the photos posted on social media with the four staff members and the photo of the Gran Malo Spicy Tamarindo was taken in the memory care kitchen due to the background in the photos. The Administrator Jill Ford and Business Office Manager Jennifer Miller also confirmed during the investigation that the social media photos and the photo of the alcohol bottle were taken at the facility. Three staff members interviewed, Staff #5 (S5), Staff #6 (S6), and Staff #7 (S7), also confirmed they observed on two different social media sites, that S1, S2, S3, and S4 were drinking alcohol while at work.

Report continued on LIC 9099-C.

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

DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 29-AS-20230117111024
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: 02/10/2023
NARRATIVE
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Based on the information obtained, there is sufficient evidence to support the allegation of ‘Staff drank alcohol while on duty’ occurred as S1 made the statement of “WHEN ITS MY BDAY EVERYONES DRINKING LOL” on social media with photos taken at the facility; a photo of an alcoholic beverage, Gran Malo Spicy Tamarindo was taken on facility grounds in the memory care kitchen; the bottle S4 was pictured drinking from on social media looks similar to the photo of Gran Malo Spicy Tamarindo taken at the facility, and three staff members observed the staff drinking alcohol while at work on social media. Therefore, the allegation is deemed substantiated at this time.

The following deficiency was observed (See LIC 9099-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 were provided.

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

DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20230117111024
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/17/2023
Section Cited
CCR
87468.1
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87468.1 Personal Rights of Residents in All Facilities (1) To be accorded dignity in their personal relationships with staff, residents, and other persons.

This requirement is not met as evidenced by:
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The Administrator shall submit a plan of correction by 02/17/2023, indicating how they will prevent this violation from occurring again.
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Based on interviews and observation, the licensee did not comply with the section cited, as a photo of an alcoholic beverage was taken in the memory care and staff posted on social media they were drinking while at work which poses an immediate H&S risk to residents in care.
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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: 02/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
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
01/17/2023 and conducted by Evaluator Kasandra Lopez
COMPLAINT CONTROL NUMBER: 29-AS-20230117111024

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: DATE:
02/10/2023
UNANNOUNCEDTIME BEGAN:
09:54 AM
MET WITH:Jennifer Miller and Ian GadeaTIME COMPLETED:
11:50 AM
ALLEGATION(S):
1
2
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Staff left residents unattended
INVESTIGATION FINDINGS:
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The allegation of ‘Staff left residents unattended’ alleges residents were left unattended while staff participated in a pot luck for S1’s birthday. Interviews revealed two staff members, in addition to the memory care activities director were working during the pot luck and residents were not left attended. Review of the staff schedule also confirmed this. Based on the information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation is deemed unsubstantiated at this time.

Exit interview and report reviewed. A copy of the report was provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 6