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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802462
Report Date: 09/25/2023
Date Signed: 09/26/2023 02:22:09 PM


Document Has Been Signed on 09/26/2023 02:22 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
WOODLAND HILLS N.ASC, 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: 104DATE:
09/25/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:17 PM
MET WITH:Sherry NazariTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Teresa Camara conducted a Case Management - Incident visit. LPA met with current Administrator/Executive Director (ED) Sherry Nazari and explained the reason for the visit.

On 9/18/2023, the facility submitted a death report for resident 1 (R1). R1 passed away on 9/17/2023. R1 was discovered in their room on the bathroom floor at approximately 8:27 p.m. by staff 1 (S1).

At 1:25 p.m. LPA spoke with the ED. At 1:37 p.m. LPA reviewed and obtained pertinent documents. At 2:09 p.m. LPA conducted a tour of the memory care unit and R1's room. At 2:33 p.m. LPA conducted an interview with staff 2 (S2). S2 was also working in the memory care unit when R1 was discovered deceased. S2 stated S1 was assigned to take care of R1. S1 was also the medication technician. S1 had taken R1 into their room at approximately 7:45 p.m. Prior to that R1 had dinner and watched television in the great room with other residents. At 8:27 p.m. S1 had gone into R1's room to give R1 their nighttime medications. S2 heard S1 yelling for help. S2 went to see what was going on and observed R1 was on the bathroom floor, not breathing and appeared deceased. S2 stayed with R1 while S1 called 9-1-1. Law enforcement and paramedics came to the facility and were at the facility for over an hour according to S2.

According to the ED, law enforcement released R1's remains to their family and R1 was not examined at the hospital or by the coroner.

Document review showed R1 was not feeling well on 9/16/2023. R1 had a slight cough and heavy breathing. The ED stated R1 was tested for COVID-19 but tested negative. Staff faxed a note on 9/16/2023 to R1's primary physician informing them of R1's symptoms and requesting a prescription for a cough suppressant. On 9/18/2023 at 12:17 p.m. the physician's office responded that they would "be in contact for further triage" but never called back.

No deficiencies were observed. Exit interview conducted and report issued to ED.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:
DATE: 09/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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