565802462-5-24-2023-29-AS-DPEA-CT7TN7-20230627145218

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802462
Report Date: 05/24/2023
Date Signed: 05/24/2023 05:48:41 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
06/18/2021 and conducted by Evaluator Kasandra Lopez

COMPLAINT CONTROL NUMBER: 29-AS-20210618140653

FACILITY NAME:	SAGE MOUNTAIN SENIOR LIVING		FACILITY NUMBER:	565802462
ADMINISTRATOR:	MARTHA BERARD		FACILITY TYPE:	740
ADDRESS:	3499 GRANDE VISTA DR		TELEPHONE:	(805) 375-0695
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91320
CAPACITY:	145	CENSUS: 105	DATE:	05/24/2023
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Jennifer Miller		TIME COMPLETED:	06:00 PM

ALLEGATION(S):

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Resident made to wait an excessive amount of time for assistance.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced subsequent complaint inspection at the facility today regarding the above allegations. The LPA met with Business Officer Manager Jennifer Miller at 10:27 AM and explained the reason for the visit.

The investigation was initiated on 06/21/2021 by LPAs Martha Guzman Chavez and Brian Balisi. During their inspection, the LPAs conducted a physical plant with Adminstrator Martha Berard, interviewed staff, residents and reviewed and obtained copies of documents relevant to the investigation On 07/22/2021, LPA Lopez conducted a subsequent visit, and conducted a physical plant tour at 12:53 PM and conducted a interviews with six residents between 1:24 PM and 3:00 PM and with one staff beginning at 3:33 PM.

Report continued on LIC 9099-C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra Lopez	TELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023

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 5

Control Number 29-AS-20210618140653

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: 05/24/2023

NARRATIVE

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Allegation: Resident made to wait an excessive amount of time for assistance

The allegation alleges staff do not respond timely to resident requests to use the restroom and response times can be one (1) to two (2) hours long. Pendent call records for all residents for the time period of 06/14/2021 through 06/21/2021 were reviewed. Records reflect on 06/20/2021, seven residents received pendent response times of 22 minutes, 24 minutes, 23 minutes, 37 minutes, 2 hours and 2 minutes, 1 hour and 14 minutes, 34 minutes, 1 hour and 38 minutes and 22 minutes (one resident had three late response times in the same day); on 06/19/2021, one resident had a response time of 34 minutes; on 06/18/2021 two residents had response times of 27 minutes and 29 minutes; on 06/17/2021 five residents had response times of 29 minutes, 30 minutes, 30 minutes, 49 minutes, and 39 minutes; on 06/16/2021 two residents had response times of 22 minutes and 57 minutes; and on 06/14/2021, two residents had response times of 41 minutes and 26 minutes. Resident interviews conducted on 06/21/2021 and on 07/22/2021 revealed five complaints from residents regarding pendent response times. Today on 05/24/2023, the LPA also substantiated a similar complaint received on 06/10/2021 (complaint control # 29-AS-20210610131205) of staff not responding to pendent calls timely. The allegation was substantiated due to record review revealing multiple pendent call wait times observed to be more than 20 minutes during the time period from 05/14/2021 through 06/14/2021 and resident and staff interviews. Based on the information obtained, there is sufficient evidence to support the allegation occurred. Therefore, the allegation of 'Resident made to wait an excessive amount of time for assistance' 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 Jennifer Miller. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra Lopez	TELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 29-AS-20210618140653

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: 05/24/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/24/2023 Section Cited CCR 87468.2	1 2 3 4 5 6 7	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:	1 2 3 4 5 6 7	The Administrator shall submit a plan by 06/07/2023 indicating how they will ensure timely pendent response times for all residents in the community.
	8 9 10 11 12 13 14	Based on interviews and record review, the licensee failed to comply with the section cited above as three residents (R2, R4, R6) had pendent call wait times in excess of 20 minutes which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 05/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

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
06/18/2021 and conducted by Evaluator Kasandra Lopez

COMPLAINT CONTROL NUMBER: 29-AS-20210618140653

FACILITY NAME:	SAGE MOUNTAIN SENIOR LIVING		FACILITY NUMBER:	565802462
ADMINISTRATOR:	MARTHA BERARD		FACILITY TYPE:	740
ADDRESS:	3499 GRANDE VISTA DR		TELEPHONE:	(805) 375-0695
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91320
CAPACITY:	145	CENSUS: 105	DATE:	05/24/2023
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Jennifer Miller		TIME COMPLETED:	06:00 PM

ALLEGATION(S):

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Facility is in disrepair/doorbells not working and unlabeled.
Residents are unable to access facility after hours.
Residents' medication and supply deliveries are delayed.
Staff doesn't provide care and assistance to residents after hours.

INVESTIGATION FINDINGS:

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Allegation: Facility is in disrepair/doorbells not working and unlabeled.

The allegation alleges the doorbells located at the main entrance and outside the memory care are unlabelled and are not working. During today's inspection, between 3:18 PM and 3:45 PM, the LPA along with Jennifer Miller and Maintenance Director Jace Evans tested the doorbells at both locations and they were observed to be operational with an auditory sound and also alerting the facility computers and staff Ipads. The LPA also observed both door bells to be labeled. Based on the information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation is deemed Unsubstantiated at this time.

Report continued on LIC 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra Lopez	TELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023

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 5

Control Number 29-AS-20210618140653

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: 05/24/2023

NARRATIVE

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Allegations: Residents are unable to access facility after hours and Residents' medication and supply deliveries are delayed.

The allegation alleges the concierge desk is only staffed until 7:30 PM which results in residents being unable to enter the facility after hours and delaying medication deliveries after hours. At the time the complaint was filed, in an effort to mitigate the spread of COVID-19, the facility locked their perimeter doors from the outside which resulted in staff having to manually open the door for residents, visitors, vendors, etc. Currently, the facility is no longer locking their perimeter doors. Interviews conducted today with Ms. Miller and during previous visits revealed the concierge desk is staffed until 8:00 PM. The facility phone number is also posted on the front door for after hours visitors which the LPA observed today. During after hours, staff carry a portable phone and receive after hour calls directly. Interviews conducted with residents on 06/21/2021 and 07/22/2021 also revealed no issues or concerns regarding gaining access inside the building after hours. One resident stated about six months prior they had a hard time accessing the building when they returned back at 11:00 PM but has had no issues since. Interviews with staff revealed they normally don't get medication deliveries after 8:00 PM but if they did, the delivery person could call the facility directly to get a hold of staff. Based on the information obtained there is insufficient evidence to support the allegations occurred. Therefore, the allegations of 'Residents are unable to access facility after hours and 'Residents' medication and supply deliveries are delayed' are deemed Unsubstantiated at this time.

Allegation: Staff doesn't provide care and assistance to residents after hours.

The allegation alleges there is only one or two staff on duty after hours and residents are not receiving assistance. A review of the staff schedule for the month of June 2021 revealed two caregivers scheduled during the PM shift and two caregivers scheduled during the NOC shift along with mostly two medication technicians during the PM shift and 1-2 medication technicians during the NOC shift. Interviews with residents revealed although there were complaints of excessive wait times for pendent calls, there was no indication that the wait times were specific to a certain time of day or shift. Based on the information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation of 'Staff doesn't provide care and assistance to residents after hours' is deemed unsubstantiated at this time.

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra Lopez	TELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023

LIC9099 (FAS) - (06/04)

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