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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565802462
Report Date: 04/12/2023
Date Signed: 04/12/2023 03:48:19 PM

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
04/05/2023 and conducted by Evaluator Kasandra Lopez
COMPLAINT CONTROL NUMBER: 29-AS-20230405082631
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
UNANNOUNCEDTIME BEGAN:
10:07 AM
MET WITH:Jennifer MillerTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Facility staff does not respond to resident's requests for assistance in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced subsequent inspection at the facility today regarding the above allegations. LPA Lopez met with Business Office Manager, Jennifer Miller at 10:07 AM and explained the reason for the inspection. Administrator Jill Ford arrived during the inspection.

During the initial inspection on 04/07/2023, the LPA conducted a brief physical plant tour with the Administrator and observed nine resident apartments between 11:13 AM and 12:20 PM. The LPA conducted interviews with three residents between 11:35 AM and 12:30 PM and with five staff members between 12:35 PM and 2:24 PM. At 2:24 PM, the LPA took of tour of the kitchen area with the Dining Room Manager. At 2:45 PM, LPA reviewed pendent call records. During today's inspection, the LPA conducted an interview with the Maintenance Director Jace Evans at 10:20 AM, reviewed facility records beginning at 10:38 AM, conducted interviews with five residents between 1:25 PM and 1:30 PM, and interviewed one staff at 2:13 PM. 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: 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.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 29-AS-20230405082631
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: 04/12/2023
NARRATIVE
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The allegation of ‘Facility staff does not respond to resident's requests for assistance in a timely manner’ alleges staff do not respond timely to Resident #1 (R1) when they use their pendent for assistance. On 04/07/2023, the LPA conducted an interview with R1 who stated pendent call wait times varies and can sometimes be thirty minutes to an hour before staff respond. During the 04/07/2023, the LPA also conducted interviews with three caregivers which revealed response times vary depending on how busy they are, but they were not aware of response time being longer than 30 minutes. The LPA reviewed the pendent call records for R1 between March 7th, 2023 and April 7th, 2023. Record revealed the following response times over 20 minutes; March 9th 38 minutes (m) 36 seconds,(s) (6:27 AM, March 10th 34m 23s (10;48 AM), March 11th 1 hour (h) 1m 12s (6:30 AM), March 11th 28m 29s (8:23 AM), March 11th 30m 46s (12:08 PM), March 11th 34m 29s (12:57 PM), March 12th 31m 17s (7:23 PM) March 13th 50m 55s (7:52 AM), March 13th 51m 2s (9:18 AM), March 14th 51m 42s (7:36 AM), March 14th 42m 49s (3:36 PM), March 14th 1 hr 4s (6:04PM), March 15th 37m 4 s (7:04 AM), March 15th 31m 41s (6:39 PM), March 1th 29m 23s 7(6:52 AM) March 17th 25m 53s (8:13 AM) March 18th 30m 6s (2:31 PM), March 18th 26m 54s (6:02 PM), March 21st 38m 30s (11:15 AM), March 22nd 2h 21s (6:34 PM), March 23rd 31m 3s (6:37 AM), March 23, 34m 57s (5:58 PM), March 23rd 29m 49 s (9:30 PM) , March 24th 1 hr 2m 23s (2:40 PM), March 25th 58m 20s (7:14 AM), March 25 49m 53s (9:27 AM) March 26thth 25m, (12:05PM), March 27th 36m 14 s (12:54 PM), March 27th 35m 14s (7:23 PM), March 28th 26m 45s (2:37PM), March 29th 50m 14 s (7:43 PM) March 30th 51m 38s (6:29 AM) March 30th 45m 41s (5:20 PM), March 31st 38m 41s (6:23 PM), April 1st 1hr 12m 24 s (7:27 AM), April 1st 34m 56 s (12:56 PM), April 2nd 49m 43s (8:40 AM) April 2nd 30m 11s (2:26 PM) April 3rd 34m 27s (7:25 AM), April 3rd 1h 12m 5s (6:17 PM), April 6th 34m 8s (6:53 PM) April 6th, 41m 15s , (8:44 PM), and April 7th 46m 18s (9:34 AM).

Based on the information obtained, there is sufficient evidence to support the allegation occurred. Therefore, the allegation of 'Facility staff does not respond to resident's requests for assistance in a timely manner’ 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 Jill Ford. 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: 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
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20230405082631
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: 04/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/20/2023
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)(4)To care, supervision, and services that meet their..needs and are delivered by staff that are sufficient in numbers, qualifications, and competency... This requirement is not met as evidenced by:
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The Administrator shall submit a plan by 04/20/2023 indicating how they will ensure timely pendent response times for R1 and all residents in the community.
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Based on interview and record review, the licensee failed to comply with the section cited above as R1 had approximately 46 pendent response time in excess of 20 minutes during a one month time period which is an immediate personal rights and health and safety risk to R1 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: 04/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023
LIC9099 (FAS) - (06/04)
Page: 3 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
04/05/2023 and conducted by Evaluator Kasandra Lopez
COMPLAINT CONTROL NUMBER: 29-AS-20230405082631

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
UNANNOUNCEDTIME BEGAN:
10:07 AM
MET WITH:Jennifer MillerTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Facility staff did not ensure that resident's apartment was free of carpet stains.
Facility staff does ensure that resident is able to maneuver their wheelchair in a safe manner at the facility.
Facility staff does not provide resident an adequate amount of food.
Facility staff does not ensure that resident's apartment is cleaned according to schedule.

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced subsequent inspection at the facility today regarding the above allegations. LPA Lopez met with Business Office Manager, Jennifer Miller at 10:07 AM and explained the reason for the inspection. Administrator Jill Ford arrived during the inspection.

During the initial inspection on 04/07/2023, the LPA conducted a brief physical plant tour with the Administrator and observed nine resident apartments between 11:13 AM and 12:20 PM. The LPA conducted interviews with three residents between 11:35 AM and 12:30 PM and with five staff members between 12:35 PM and 2:24 PM. At 2:24 PM, the LPA took of tour of the kitchen area with the Dining Room Manager. At 2:45 PM, LPA reviewed pendent call records. During today's inspection, the LPA conducted an interview with the Maintenance Director Jace Evans at 10:20 AM, reviewed facility records beginning at 10:38 AM, conducted interviews with five residents between 1:25 PM and 1:30 PM, and interviewed one staff at 2:13 PM. Report continued on LIC 9099-C.
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: 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.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20230405082631
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: 04/12/2023
NARRATIVE
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The allegation of ‘Facility staff did not ensure that resident's apartment was free of carpet stains’ alleges that R1’s carpet was supposed to be brand new upon move in, but the carpet has stains and has not been cleaned as requested. During the initial inspection on 04/07/2023, the LPA observed R1’s apartment and observed a dime size stain in the living and some smaller spots on the carpet near the bathroom. Facility record review and interviews revealed the following. R1 moved into the apartment on 01/12/2023. An invoice from Interior Logic Group reflects carpet was installed on 12/06/2022. Interviews with Maintenance Director Jace Evans revealed the apartment remained vacant after the carpet was installed until R1 moved in. Facility work orders reveals a carpet cleaning request was submitted on 01/23/2023 and it was completed on 01/26/2023. On 02/01/2023 another request for the carpet spots to be cleaned was submitted and it was cleaned the same day. On 02/03/2023, R1 requested the carpet to be cleaned again which was cleaned the same day. On 03/25/2023 a request to clean the carpet outside the bathroom was requested and it was completed on 04/03/2023. During the interview with Mr. Evans he stated they have not received any requests to clean the carpet since 03/25/2023. Based on the information obtained, there is insufficient evidence to support the allegation ‘Facility staff did not ensure that resident's apartment was free of carpet stains’ occurred. Therefore, the allegation is deemed unsubstantiated at this time.

The allegation of 'Facility staff does ensure that resident is able to maneuver their wheelchair in a safe manner at the facility' alleges R1’s request for a flooring solution to aid in wheelchair maneuvering has been denied. Interviews today with Maintenance Director Jace Evans revealed the facility is currently working on a solution for the transition piece between the carpet in the living room and the flooring in the kitchen and stated R1’s request has not been denied. Mr. Evans showed the LPA several text messages between himself and the sales Representative from Interior Logic Group Property between March 3rd, 2023 and April 11th 2023 regarding the new transition piece for R1’s apartment. Mr. Evans said several transition pieces have been brought to the facility by the carpet company during this time, but they did not correct the issue. Mr. Evans said on Monday the carpet company is scheduled to come out and fix the issue. Based on the information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation of ‘Facility staff does ensure that resident is able to maneuver their wheelchair in a safe manner’ is deemed unsubstantiated at this time.

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: 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
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20230405082631
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: 04/12/2023
NARRATIVE
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The allegation of ‘Facility staff does not provide resident an adequate amount of food’ alleges portion sizes of food are sometimes small and second helpings are denied. During the interview with R1, they stated sometimes proteins are small in quantity and when they have requested two servings of a meal on their room service meal slip request, they do not always receive it. The interview with the Dining Room Manager on 04/07/2023 revealed they were not aware of requests for seconds being denied. The LPA also toured the kitchen with Dining Room Manager and was shown multiple signs posted in multiple locations in the kitchen to help kitchen staff be aware of special diets, requests, etc. for residents. During the tour, the LPA observed signs for R1 reminding staff to follow what's written on the meal slip request and to make sure the order is complete before delivering tray. Interviews with two residents on 04/07/2023 and five residents during today’s inspection revealed no issues or concerns regarding portion size and revealed seconds are provided upon request. Based on the information obtained, there is insufficient evidence to support the allegation of ‘Facility staff does not provide resident an adequate amount of food’ occurred. Therefore, the allegation is deemed Unsubstantiated at this time.

The allegation of ‘Facility staff does not ensure that resident's apartment is cleaned according to schedule’ alleges house keeping does not always come weekly as scheduled. Interviews with seven residents on 04/07/2023 and during today’s visit revealed house keeping services are provided once a week and there are no issues or concerns regarding services not being provided as scheduled. Interviews with staff revealed residents are provided house keeping services weekly. Based on the information obtained there is insufficient evidence to support the allegation of Facility staff does not ensure that resident's apartment is cleaned according to schedule. Therefore, the allegation is deemed unsubstantiated at this time.

Exit interview conducted with Jill Ford. 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
LIC9099 (FAS) - (06/04)
Page: 6 of 6