565802462-2-16-2023-29-AS-DPEA-CT7TUK-20230627150225

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802462
Report Date: 02/16/2023
Date Signed: 02/16/2023 02:46:20 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: 110	DATE:	02/16/2023
		UNANNOUNCED	TIME BEGAN:	10:03 AM
MET WITH:	Jill Ford		TIME COMPLETED:	02:50 PM

ALLEGATION(S):

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Facility does not provide a comfortable environment for residents.

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 allegation. The LPA met with Administrator Jill Ford at 10:11 AM and explained the reason for the visit.

The allegation of 'Facility does not provide a comfortable environment for residents' alleges residents are fearful to speak with the long term care ombudsman. During the course of the investigation, on 07/21/2021, the LPA interviewed with six residents between 1:24 PM and 3:00 PM. Interviews revealed residents interviewed had no fear of speaking with the long term care ombudsman or fear of retaliation by anyone if they spoke with the ombudsman. Based on this information, there is insufficient evidence to support the allegation occurred. Therefore, the allegation is deemed unsubstantiated at this time.

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: 02/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023

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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