565802462-5-24-2023-29-AS-DPEA-CT7TUJ-20230627150225

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802462
Report Date: 05/24/2023
Date Signed: 05/24/2023 05:46:15 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
07/20/2021 and conducted by Evaluator Kasandra Lopez

COMPLAINT CONTROL NUMBER: 29-AS-20210720151601

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:	05:45 PM

ALLEGATION(S):

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Insufficient staffing

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced subsequent complaint inspection at the facility to deliver the findings for the above allegation. The LPA met with Business Office Manager Jennifer Miller and informed her of the reason for today's inspection.

During a previous inspection on 07/22/2021, the LPA met with interim Administrator Jacob Primeau and reviewed facility records beginning at 11:42 AM and conducted interviews with six residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6) during the time period of 1:24 PM and 3:00 PM and interviewed Staff #1 at 3:33 PM.

Allegation: Insufficient staffing
The allegation alleges the complainant did not receive information timely due staff on duty not have access to the resident roster and staffing shortage due to the facility having an interim Administrator.
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)

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Control Number 29-AS-20210720151601

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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Interviews during this investigation with Jacob Primeau and during a previous investigation under complaint control # 29-AS-20210610131205 with Business Office Manager Anabel Amaya on 06/14/2021 revealed, the Administrator at the time Martha Berard was on leave but the facility had interim Administrators and multiple staff from their Regional Office to provide administrative support for the facility. Also at the time the complaint was filed, reception did not have access to the resident roster and it had to be printed by the Business Office Manager, which it was done during the complainant's visit. Based on the information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation of 'Insufficient staffing' 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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