565802462-3-2-2022-29-AS-KLOZ-CC5W49-20220302155711

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565802462
Report Date: 03/02/2022
Date Signed: 03/02/2022 03:58:36 PM

Document Has Been Signed on 03/02/2022 03:58 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: 98	DATE:	03/02/2022
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	09:58 AM
MET WITH:	Jill Ford		TIME COMPLETED:	03:25 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 Case Management - Incident inspection at the facility today. The LPA met with Administrator Jill Ford at 10:04 AM and explained the reason for today's inspection. On 02/17/2022, Community Care Licensing received a written report of an incident occurring on 02/12/2022 regarding Resident #1 (R1) which involved Staff #1 (S1). On 02/18/2022, LPA Ashley Morgan followed up on the written report telephonically with Administrator Jill Ford and requested pertinent documentation, including a copy of the report of Suspected Dependent Adult/Elder Abuse form (SOC 341) that was cross reported to the appropriate agencies. On 02/22/2022, LPA Lopez emailed the Administrator requesting the pertinent documentation and a copy of the SOC 341 again. During today's inspection, the LPA met with and interviewed Administrator, Jill Ford, Director of Health and Wellness, Nicolle Hoznor, , LVN Vivian Reyes, Business Office Manager, Jennifer Miller, and three staff members between 10:04 AM and 1:30 PM. LPA also reviewed facility records and obtained pertinent copies. The LPA has determined further investigation is needed and will return at a later date to complete the investigation. During today's inspection, the LPA also followed up on a self reported incident of which on 01/29/2022, three memory care residents eloped through the delayed egress patio and were observed by staff in front of the building unassisted. No injuries were reported and family members were informed. The LPA spoke with the Administrator on 02/01/2022 regarding the incident and it was reported staff in the memory care did not hear the alarm as they were busy with other residents. 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: 03/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022

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: 03/02/2022

NARRATIVE

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During today's inspection, the LPA conducted a tour of the Memory Care unit at 1:34 PM with Administrator Jill Ford, LVN Vivian Reyes, and Maintenance Director Jace Evans. The memory care outdoor patio has two delayed egress doors that exit the patio and lead into the backside of the property and surrounding areas. Mr. Evans tested the far right delayed egress door while the LPA stayed inside the memory dining room area. The alarm was heard very faintly from inside the dining room and would not be able to be heard audibly in any other part of the memory care unit. Mr. Evans stated the caregiver's iPods are also alerted when the alarm is activated. During the inspection, it was observed that all the caregiver iPods were in the medication room area docking station and no staff had any iPods on their person. Therefore, no memory care staff would be alerted if the delayed egress doors were opened. During the inspection, Mr. Evans stated a modification could be made so that the alarm would alert staff audibly inside the memory care when activated. Pursuant to Title 22 CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D).

Exit interview conducted and the report and deficiency were discussed with the Administrator. A copy of the report was emailed.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra Lopez	TELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/02/2022 03:58 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: 03/02/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/11/2022 Section Cited	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by:
	8 9 10 11 12 13 14	Based on observation and interviews, the licensee failed to comply with the section cited above as the delayed egress system is not loud enough for staff to her audibly inside all areas of the memory care and staff were observed to not be using iPods which would alert them of the egress system which poses an immediate safety risk to residents in care.	8 9 10 11 12 13 14	By 03/11/2022, the Administrator shall submit proof a modification has been made so that the alarm is audibly heard inside the memory 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 Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra Lopez	TELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022

LIC809 (FAS) - (06/04)

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