565802462-7-22-2021-29-AS-DPEA-CT7TN8-20230627145218

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802462
Report Date: 07/22/2021
Date Signed: 07/22/2021 06:02:34 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
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: 72	DATE:	07/22/2021
		UNANNOUNCED	TIME BEGAN:	11:19 AM
MET WITH:	Jacob Primeau		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Facility trash is not emptied on a regular basis.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced initial 10 day complaint investigation at the facility today. At 11:26 AM the LPA met with interim Administrator Jacob Primeau and explained the reason for today's inspection.
During today's inspection for the above allegation, the LPA conducted a physical plant tour at 12:53 PM and conducted interviews with six residents between 1:24 PM and 3:00 PM and with one staff beginning at 3:33 PM. Interviews revealed no issues or concerns regarding the laundry room trash or the resident room trash not being removed on a regular basis. During the physical plant tour, the LPA observed the laundry rooms located on each floor. The laundry rooms had trash cans with lids. The trash cans had some trash present but were not in need of being emptied. The allegation alleges the trash can in the laundry room is not being emptied on a regular basis. Based on interviews conducted today and during a previous inspection on 06/21/2021 by LPAs Martha Guzman Chavez and Brian Balisi, the allegation is deemed unsubstantiated at this time. Exit interview conducted and the report was reviewed with the Administrator. A copy of the report and appeal rights will be emailed.

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: 07/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021

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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