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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802462
Report Date: 04/12/2023
Date Signed: 04/12/2023 04:03:11 PM


Document Has Been Signed on 04/12/2023 04:03 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 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:
04/12/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Jennifer MillerTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Case-Management Incident inspection regarding a death report pertaining to Resident #1 (R1). The LPA met with Business Manager Jennifer Miller and explained the reason for the visit.

On 04/07/2023, The Department received a Death Report (624A) pertaining to Resident #1 (R1) who was hospitalized on 03/31/2023 and expired at the hospital on 04/01/2023. The cause of death is unknown at this time. During today's visit the LPA met with Director of Health and Wellness Ian Gadea. Mr. Gadea contacted the mortuary during today's inspection but was advised the death report would not ready for one week. Mr. Gadea will forward a copy to the LPA as soon as it is received. During the inspection the LPA reviewed records for R1.

No deficiencies are being cited at this time. Upon receipt of the death certificate, the LPA will return if further investigation is needed.

Exit interview conducted. A copy of the report was provided.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2023
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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