565802462-7-25-2023-29-AS-DPEA-CU9VVW-20230731164702

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802462
Report Date: 07/25/2023
Date Signed: 07/25/2023 04:09:52 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
06/26/2023 and conducted by Evaluator Kasandra Lopez

COMPLAINT CONTROL NUMBER: 29-AS-20230626122339

FACILITY NAME:	SAGE MOUNTAIN SENIOR LIVING		FACILITY NUMBER:	565802462
ADMINISTRATOR:	JANELLE LOPEZ		FACILITY TYPE:	740
ADDRESS:	3499 GRANDE VISTA DR		TELEPHONE:	(805) 375-0695
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91320
CAPACITY:	145	CENSUS: 109	DATE:	07/25/2023
		UNANNOUNCED	TIME BEGAN:	12:26 PM
MET WITH:	Jennifer Miller		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Resident was sexually harassed while in care.

INVESTIGATION FINDINGS:

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

The allegation of 'Resident was sexually harassed while in care' alleges that an unknown person exposed them self to Resident #1 (R1) while on the patio during an unknown date or time.

The investigation for this complaint was initiated on 06/30/2023. During the inspection, between 10:01 AM and 12:30 PM, LPA Lopez reviewed facility records and conducted interviews with one staff member and four residents. The LPA attempted to interview R1 but they were not available for interview.

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: 07/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2023

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-20230626122339

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: 07/25/2023

NARRATIVE

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On 07/07/2023, the LPA conducted a subsequent inspection and conducted interviews with two staff members between 11:55 AM and 1:54 PM. The LPA was advised that R1 was not available for interview on this day also.

During today's inspection between 12:55 PM and 3:15 PM, the LPA conducted interviews with Director of Nursing Ian Gadea, three residents, and three staff members. The LPA was advised during the inspection that R1 was still not available for interview. At 2:54 PM, the LPA conducted a telephone interview with a family member of R1.

Interviews with residents revealed no issues or concerns with any individuals at the facility acting inappropriately with them or exposing them self to the residents. Staff interviews revealed no reports of any individuals being sexually inappropriate with any of the residents. The interview with R1's family member also revealed no reports of any individual at the facility exposing them self or being sexually inappropriate with R1.

Based on the information obtained, there is insufficient evidence to support the allegation of resident was sexually harassed while in care. Therefore, the allegation is deemed unsubstantiated at this time.

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra Lopez	TELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2023

LIC9099 (FAS) - (06/04)

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