565802462-7-12-2023-29-AS-DPEA-CU4M89-20230726092244

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802462
Report Date: 07/12/2023
Date Signed: 07/12/2023 04:07:03 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
03/22/2022 and conducted by Evaluator Kasandra Lopez

COMPLAINT CONTROL NUMBER: 29-AS-20220322104533

FACILITY NAME:	SAGE MOUNTAIN SENIOR LIVING		FACILITY NUMBER:	565802462
ADMINISTRATOR:	JILL FORD		FACILITY TYPE:	740
ADDRESS:	3499 GRANDE VISTA DR		TELEPHONE:	(805) 375-0695
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91320
CAPACITY:	145	CENSUS: 114	DATE:	07/12/2023
		UNANNOUNCED	TIME BEGAN:	01:49 PM
MET WITH:	Julius Osorio		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Physical abuse to resident while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) KaSandra Lopez conducted a subsequent complaint visit to deliver findings for the above allegations. LPA met with interim Administrator Julius Osorio and explained the reason for the visit.

On 03/22/2022, Community Care Licensing Division (CCLD) received a complaint regarding an allegation of physical abuse. It was reported that on 03/18/2022, Resident #1 (R1) arrived at the hospital with a laceration to their labia. R1 allegedly fell while being assisted in the shower but there was concern due to the injury being in an odd location and the victim is wheelchair bound.
On 03/22/2022, LPA Lopez conducted an unannounced initial complaint inspection at the facility and met with Administrator at the time Jill Ford, and Director of Health Wellness at the time Nicolle Hoznor. A review of facility records for R1 revealed an internal Resident Incident report dated 03/18/22 reflects on 03/18/2022 at 7:35 a.m., R1 had a witnessed fall. Staff #1 (S1) was identified as the witness. It was reported that R1 stated they slid down to the floor from the shower bench. 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: 07/12/2023

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.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220322104533

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: 07/12/2023

NARRATIVE

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S1 reported when they were transferring R1 to the shower bench, R1 lost their balance and S1 assisted the resident down to the floor. R1 sustained a skin tear and paramedics were called. The internal report was completed by Staff #2 (S2). Ms. Hoznor stated R1 is a two person assist and a fall risk, but they have not had any falls since Hoznor has worked at the facility. The 08/22/2021, service plan for R1 revealed R1 is a two-person assist with transfers. During the visit, the LPA was advised that S1 was an agency staff and not a permanent employee of the facility. Both S1 and S2 were not available for interview during this visit.

On 03/22/2022 at 6:46 p.m., CCLD received an Unusual Incident/Injury Report (LIC624) regarding the 03/18/2022 incident with R1.

On 07/07/2023, the LPA conducted a subsequent inspection at the facility and conducted an interview with S2, R1, and the family member of R1 between 11:55 a.m. and 1:55 p.m. The LPA attempted to obtain contact information for S1, but it was not available.

Interviews with R1 and their family member revealed that R1 did not recall the incident but R1’s family member did recall the incident. The family member stated they met R1 at the hospital when the incident occurred and although, a laceration to the labia was in an odd place for a fall, the family member did not suspect any type of abuse occurred by any staff members at the facility. The family member also stated at the time of the incident, R1 never suggested any type of abuse occurred. Interviews revealed S2 was not present when the fall occurred but arrived afterwards due to the resident being injured. S1 reported to S2 that the injury occurred when the resident slid off the shower bench. S1 was the only staff member present when the injury occurred.

It has been determined there is insufficient evidence to support the allegation of physical abuse to resident while in care occurred. Therefore, the allegation is deemed unsubstantiated at this time. Exit interview and report reviewed with the interim Administrator.

Deficiencies observed during the investigation will be addressed under a separate report.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra Lopez	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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