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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565802462
Report Date: 02/16/2023
Date Signed: 02/16/2023 02:46:59 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
08/24/2021 and conducted by Evaluator Kasandra Lopez
COMPLAINT CONTROL NUMBER: 29-AS-20210824100751
FACILITY NAME:SAGE MOUNTAIN SENIOR LIVINGFACILITY NUMBER:
565802462
ADMINISTRATOR:MARTHA BERARDFACILITY TYPE:
740
ADDRESS:3499 GRANDE VISTA DRTELEPHONE:
(805) 375-0695
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91320
CAPACITY:145CENSUS: 110DATE:
02/16/2023
UNANNOUNCEDTIME BEGAN:
10:03 AM
MET WITH:Jill FordTIME COMPLETED:
02:50 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Licensee is allowing resident's personal rights to be violated
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced subsequent complaint inspection regarding the above allegation. The LPA met with Jill Ford at 10:11 AM and explained the reason for the visit.
The allegation of 'Licensee is allowing resident's personal rights to be violated' alleges Resident #1 (R1) is blocking and/or restricting the Certified Ombudsman from attending Resident Council meetings and the facility is allowing it. On 08/24/2021, the LPA conducted interviews with seven residents, including R1, between 1:50 PM and 2:59 PM. The interview with R1 revealed they have invited the ombudsman to council meetings in the past when they have had problems but they are not always needed at every meeting. Interviews with the other six residents revealed no one has ever told them not to invite the ombudsman to their council meeting and they had no issues or concerns if the ombudsman was invited. 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 conducted and report reviewed. A copy of the report and appeal rights were 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: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023
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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