565802462-5-24-2023-29-AS-DPEA-CT7T4Q-20230627142418

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802462
Report Date: 05/24/2023
Date Signed: 05/24/2023 05:22:51 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
06/10/2021 and conducted by Evaluator Kasandra Lopez

COMPLAINT CONTROL NUMBER: 29-AS-20210610131205

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: 106	DATE:	05/24/2023
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Jennifer Miller		TIME COMPLETED:	05:25 PM

ALLEGATION(S):

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Medications not given to resident timely
Staff mismanaged resident's medication
Staff does not respond to pendent calls timely

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.

During a previous visit on 06/14/2021, between 10:58 AM and 12:45 PM, LPA Lopez conducted interviews with Resident #1 (R1), Resident #2 (R2), Resident #3 (R3), Resident #4 (R4), and Resident #5 (R5). Beginning at 12:54 PM, the LPA reviewed medications and records for R1. At 1:00 PM the LPA conducted an interview with Staff #1 (S1). At 2:21 PM the LPA conducted an interview with Staff #2 (S2). On a subsequent visit, on 07/22/2021 the LPA conducted interviews with one resident (Resident #6) and one staff (Staff #3).

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 6

Control Number 29-AS-20210610131205

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: Medications not given to resident timely

The allegation alleges on 06/05/2021, staff only brought Resident #1 (R1) three of R1’s AM medications when R1 receives more than three AM medications. When R1 questioned where the other medications where, staff stated they would return with them. It was alleged after lunch, R1 still had not received the missed AM medications.

Medication record review revealed, R1 received ten (10) AM medication to be dispensed at 9:00 AM. Medication Passing Detail records for R1 on 06/05/2021, revealed R1 received six (6) of their AM medications at 9:00 AM and four (4) of their AM medications at 12:24 PM. Based on the information obtained, there is sufficient evidence to support the allegation occurred. Therefore, the allegation of 'Medications not given to resident timely' is deemed Substantiated at this time.

Allegation: Staff mismanaged resident's medication

The allegation alleges R1 did not receive all their medications and facility staff acknowledged they failed to order R1's medications timely. Medication Passing Detail records for R1 revealed R1 did not receive two (2) AM medications on 06/06/2021 (Asprin and Losartan Pot 50 MG) due to the medication being on route for delivery. Based on the information obtained, there is sufficient evidence to support the allegation occurred. Therefore, the allegation of 'Staff mismanaged resident's medication' is deemed Substantiated at this time.

Allegation: Staff does not respond to pendent calls timely

The allegation alleges residents have to wait 20 minutes or longer for staff to respond to pendent calls. During the investigation, the LPA interviewed six residents. Five out of the six residents interviewed used their pendent when they need assistance and reported they sometimes have to wait 20 minutes to over an hour for staff to respond to their call. Pendent call records were reviewed for 05/14/2021 through 06/14/2021 revealed the following. Report continued on LIC 9099-C.

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: 2 of 6

Control Number 29-AS-20210610131205

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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On 05/23/2021 and 05/14/2021 R2 had to wait 20 minutes for staff response; R4 had the following wait times, on 05/15/2021 24 minutes, 05/18/2021 30 minutes, 05/21/2021 36 minutes, 05/31/2021 32 minutes, 06/08/2021 28 minutes, 06/11/2023, 20 minutes, and 06/14/2021 22 minutes, R6 had the following wait time, on 06/01/2021 45 minutes, 06/02/2021 22 minutes, 06/02/2021 58 minutes, 06/03/2021 29 minutes, 06/03/2021 35 minutes, 06/04/2021 1 hour and 16 minutes, 06/05/2021 53 minutes, 06/07/2021 1 hour 2 minutes, 06/08/2021 1 hour 4 minutes, 06/10/2021 1 hour 19 minutes, 06/10/2021 32 minutes, 06/11/2021 1 hr 12 minutes, 06/14/2021 40 minutes.

During the 06/14/2021 visit, the LPA met with Business Office Manager at the time Annabel Amaya, who reported they did have issues with staff at the time and were in the process of hiring additional staff but were using agency staff to help supplement. Ms. Amaya said staff should be responding within 10 minutes to pendent calls. During the interview with S1 they stated recently due to there being only one staff (S1) and one agency staff on shift, they did not respond timely to R6 and it took over 30 minutes for S1 to respond.

Based on the information obtained, there is sufficient evidence to support the allegation occurred. Therefore the allegation of 'Staff does not respond to pendent calls timely' 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 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
06/10/2021 and conducted by Evaluator Kasandra Lopez

COMPLAINT CONTROL NUMBER: 29-AS-20210610131205

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:	DATE:	05/24/2023
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Jennifer Miller		TIME COMPLETED:	05:25 PM

ALLEGATION(S):

1
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5
6
7
8
9

Administrator does not spend a sufficient amount of time in the facility
Staff forged facility records

INVESTIGATION FINDINGS:

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Allegation: Administrator does not spend a sufficient amount of time in the facility

The allegation alleges Administrator at the time, Martha Berard did not spend a sufficient amount of time in the facility. Interviews with Business Office Manager at the time, Anabel Amaya on 06/14/2021 and interim Administrator Jacob Primeau on 07/22/2021 revealed Administrator Martha Berard was currently on leave but multiple staff from their Regional Office had been providing weekly administrative support at the facility in the interim. Based on the information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation of 'Administrator does not spend a sufficient amount of time in the facility' 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 6

Control Number 29-AS-20210610131205

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: Staff falsified facility records

The allegation alleges Staff #4 (S4) on 06/05/2021, S4 documented on R1's records that all their medication had been given that day when it had not. Record review revealed on 06/05/2021, Staff #5 (S5) dispensed the AM medications and not S4. On 06/06/2021, S4 documented R1 did not receive two medications because they were on order from the pharmacy. Both S4 and S5 no longer work for the company. Based on the information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation of 'Staff falsified facility records' is deemed Unsubstantiated at this time.

Exit interview conducted. A copy of the report 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: 5 of 6

Control Number 29-AS-20210610131205

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 06/07/2023 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (a) (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Administrator shall submit proof of an in-service training with current medication techs to ensure the deficiency does not occur again. Proof of training shall be submitted by 06/07/2023.
	8 9 10 11 12 13 14	Based on record review and interview, the licensee failed to comply with the section cited above R1 received their medication late and R1 did not receive their medication due it not being ordered timely which poses an immediate health risk to R1 in care.	8 9 10 11 12 13 14
Type A 06/07/2023 Section Cited CCR 87468.2(a)(4)	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

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)

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