<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802462
Report Date: 07/12/2023
Date Signed: 07/12/2023 04:03:19 PM


Document Has Been Signed on 07/12/2023 04:03 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 LIVINGFACILITY NUMBER:
565802462
ADMINISTRATOR:JANELLE LOPEZFACILITY TYPE:
740
ADDRESS:3499 GRANDE VISTA DRTELEPHONE:
(805) 375-0695
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91320
CAPACITY:145CENSUS: 114DATE:
07/12/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:49 PM
MET WITH:Julius OsorioTIME COMPLETED:
04:10 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Case Management Incident visit at the facility today. The LPA met with interim Administrator Julius Osorio and explained the reason for the inspection.

On 07/11/2023, The Department received a Report of Suspected Dependent Adult/Elder Abuse (SOC 341) completed 07/07/2023 from interim Administrator Julius Osorio. The SOC 341 report pertained to Resident #1 (R1) and Staff #1 (S1) for an alleged incident that occurred on 07/06/2023. On 07/11/2023, the LPA spoke with Mr. Osorio on telephone regarding the alleged incident and he stated S1 is currently on leave pending an investigation.

During today's inspection, the LPA reviewed facility records and obtained pertinent copies. When the LPA arrived there was a Ventura County Sheriff's vehicle outside the building. The LPA was advised that law enforcement was speaking with R1 at the time. A copy of the report number was obtained.

Further investigation is needed. Community Care Licensing Division's (CCLD) Investigation Branch (IB) Investigator Juan Lozano has been assigned to the investigation.

Exit interview conducted and report reviewed. A copy of the report was provided.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1