565802462-7-7-2023-29-AS-DPEA-CTXVDL-20230721162056

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802462
Report Date: 07/07/2023
Date Signed: 07/07/2023 03:35:53 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
08/26/2021 and conducted by Evaluator Kasandra Lopez

COMPLAINT CONTROL NUMBER: 29-AS-20210826104708

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: 115	DATE:	07/07/2023
		UNANNOUNCED	TIME BEGAN:	10:19 AM
MET WITH:	Jennifer Miller		TIME COMPLETED:	03:40 PM

ALLEGATION(S):

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Residents are not receiving appropriate care
Resident records are not accurate

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced subsequent complaint investigation regarding the above allegations. The LPA met with Business Office Manager Jennifer Miller and explained the reason for the inspection.

During a previous inspection on 09/01/2021, the LPA reviewed resident records beginning at 2:16 PM and obtained pertinent copies. At 3:54 PM, an interview was conducted with Resident #1 (R1).

During today's inspection between 10:30 AM and 2:30 PM, the LPA reviewed additional facility records and conducted interviews with three staff members.

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: 07/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023

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-20210826104708

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: 07/07/2023

NARRATIVE

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Allegation: Resident records are not accurate

The allegation alleges Resident #1 (R1) had diagnosis of early onset dementia for two years and recently had their diagnosis changed by the physician and the resident's care plan does not include provision to keep the resident safe given their previous dementia diagnosis. Interviews and record review revealed R1 moved into assisted living on 09/30/2020 and remained in assisted living until they passed away on 03/10/2022. On 09/30/2020, R1 had a medical assessment conducted by their physician and the box for dementia was checked and the confused/disorientated box was checked. On the report, the doctor notes the patient was previously very smart and an attorney who has had increasing confusion since surgery for metastatic colon cancer in January 2020 with chemotherapy ending in July 2020.

On 08/05/2021, R1 had an updated medical assessment with a new physician. On this report, the MCI box was checked instead of dementia and the confused/disorientated was not checked this time. On the 08/05/2021 report it is noted the resident refused to sign the medical report as they disagreed with the doctor's assessment. On 09/15/2021, R1 had another updated medical assessment by the same doctor from 08/05/2021 and the assessment remained the same from the 08/05/2021 report date, although it was added that R1 may have a glass of wine daily.

The 09/30/2020 assessment conducted by the facility nurse for R1 indicated R1 needed assistance with dressing, grooming, and mobility but had no cognition/orientation impairment and was alert and orientated to person, place, and time, with no behavior issues or an elopement risk. An undated mini-mental state examination for R1 had a score of 27 out of 30 which was within the normal range. On 05/19/2021, R1 had an updated assessment which indicated R1 was independent for dressing grooming, bathing, and mobility, and had no cognition/orientation impairment and was alert and orientated to person, place, and time with no behavior issues or an elopement risk.

During the interview with R1 on 09/01/2021, they stated they did not agree with the doctor's diagnosis of MCI or the previous' doctor's assessment of dementia and stated they managed their own medical treatment and finances. Interviews with staff today revealed no issues or concerns pertaining to R1 residing in assisted living until their passing. Based on the information obtained, there is insufficient evidence to support the allegation of Resident records are not accurate occurred, Therefore, the allegation is deemed unsubstantiated at this time. 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: 07/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20210826104708

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: 07/07/2023

NARRATIVE

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Allegation: Residents are not receiving appropriate care

The allegation alleges Resident #2 (R2) and Resident #3 (R3) who both lived in assisted living, wander and are confused and should be in memory care or receiving 1:1 support. Record review revealed R2 had a diagnosis of dementia and noted confusion at times. R2 was given the mini-mental state examination on 08/25/2021 and scored a 24 which fell under the category of mild degree of impairment (20-25). Record review did not reveal any wandering behaviors. Record review for R3 revealed R3 had no diagnosis of dementia or MCI and no indication of any confusion. Interviews with staff revealed although R2 was confused at times, they still felt assisted living was an appropriate placement for R2 and R2 remained in assisted living until they moved out of the facility on 07/15/2022. Staff interviewed did not recall R3 and could not provide any additional information pertaining to R3. R3 passed away on 02/11/2022.

Based on the information obtained, there is insufficient evidence to support the allegation of 'Residents are not receiving appropriate care'. Therefore, the allegation is deemed unsubstantiated at this time.

Exit interview and report reviewed with Ms. Miller and Regional Nurse Leticia Higares. A copy of the report and appeal rights

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra Lopez	TELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023

LIC9099 (FAS) - (06/04)

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