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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565802462
Report Date: 08/01/2023
Date Signed: 08/01/2023 04:53:58 PM

Substantiated


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
03/21/2022 and conducted by Evaluator Kasandra Lopez
COMPLAINT CONTROL NUMBER: 29-AS-20220321114529
FACILITY NAME:SAGE MOUNTAIN SENIOR LIVINGFACILITY NUMBER:
565802462
ADMINISTRATOR:JILL FORDFACILITY TYPE:
740
ADDRESS:3499 GRANDE VISTA DRTELEPHONE:
(805) 375-0695
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91320
CAPACITY:145CENSUS: 109DATE:
08/01/2023
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Jennifer MillerTIME COMPLETED:
05:05 PM
ALLEGATION(S):
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Facility staff initial training is incomplete
Facility staff annual training is not completed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced subsequent complaint inspection at the facility regarding the above allegations. The LPA met with Business Office Manager Jennifer Miller and New Administrator Shahrzad "Sherry" Nazari and explained the reason for the inspection.

The investigation for the complaint was initiated on 03/22/2022. During the initial visit, the LPA conducted interviews with Administrator at the time, Jill Ford, and Director of Health and Wellness at the time, Nicole Hoznor and conducted record review between 3:10 PM and 4:30 PM. Pertinent copies of records were obtained. At 4:33 PM, the LPA conducted a physical plant tour of the kitchen.

On 07/26/2022, a subsequent visit was conducted. The LPA met with Culinary Director Michael Tabada, toured the kitchen, and observed the food storage areas. Between 12:45 PM and 2:30 PM, the LPA conducted interviews with six staff members.
Report continued on LIC 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 29-AS-20220321114529
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: 08/01/2023
NARRATIVE
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On 02/16/2023, the LPA discussed the allegations with the Administrator at the time Jill Ford and obtained copies of additional facility records.

During today's inspection, the LPA reviewed facility records beginning at 11:41 AM and conducted interviews with Business Office Manager Jennifer Miller.

Allegations: Facility staff initial training is incomplete and Facility staff annual training is not completed

The allegation alleges new staff are working with residents prior to receiving their completed initial training and staff are not up to date on their annual training. The LPA reviewed record for six caregivers and or med-techs.

Staff #1 (S1) was hired as a caregiver on 03/15/2022. Record review revealed S1 received 5.5 hours of training through Relias on 03/23/2022 and .50 hours of training on 06/24/2022 and no further record of the required 40 hours of initial training within the first four weeks of employment or the annual training of a total of 20 hours for direct care staff. Records reflect on 07/02/2022, S1 received 24 hours of initial medication training. On 02/08/2023, 03/17/2023, and 05/30/2023, S1 received a medication in-service training but the hours of training received were not documented.

Staff #2 (S2) is a medication technician hired on 02/03/2022. Record review revealed S2 received 24 hours of initial medication training on 2/3/22, 2/4/22, 2/5/22, and 2/10/22. S2 received med tech in-service training on 02/08/2023, although there is no record of how long the training was.

Staff #3 (S3) was hired on 05/21/2021 as a caregiver. The facility has no record of S3 receiving 40 hours of initial training within the first four weeks of employment or proof of 20 hours of annual training in 2022 or 2023. S3 later became a med-tech and received 24 hours of medication training in June 2021 and August 2021 but there is no record of S3 receiving annual medication training in 2022 and medication training received in 2023 did not reflect how long the training was.

Report continued on LIC 9099-C.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 29-AS-20220321114529
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: 08/01/2023
NARRATIVE
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Staff #4 (S4) was hired on 09/23/2022 as a caregiver. Records reflect S4 received only three hours of training from Relias in October 2022, 14.25 hours of documented training in Relias in 2023, and one hour of in-service training on 07/25/2023.

Record review also revealed no proof of current first aid for all six staff files reviewed.

Based on the information received, there is sufficient evidence to support the allegations of facility staff initial training is incomplete and facility staff annual training is not completed. Therefore, the allegations are deemed substantiated at this time.

The following deficiencies were observed (See LIC 9099-D.) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview and report reviewed with Jennifer Miller, Business Office Manager and Sherry Nazari Administrator. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 29-AS-20220321114529
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/22/2023
Section Cited
HSC
1569.625(b)(1)(2)
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ยง1569.625 (b)(1) The department shall.. require staff members of RCFE's who assist residents with personal ADL's to receive appropriate training. This training shall consist of 40 hours of training. (2) In addition..training requirements shall also include an additional 20 hours annually.
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The Business Office Manager and Administrator agrees to submit proof S1, S3, and S4 have proof of all required training to CCL by 08/22/2023.
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This requirement is not met as evidence by: Based on record review, the licensee failed to comply with the section above as three out of four caregiver files did not have proof of required initial training and/or annual training which poses a potential risk to residents in care.
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Type B
08/22/2023
Section Cited
HSC
1569.69
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1569.69 (b) Each employee who received training and passed.. (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period.
This requirement is not met as evidence by:
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The Business Office Manager agrees to submit proof S1, S2, and S3, have current annual medication training to CCL by 08/22/2023.
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Based on record review, the licensee failed to comply with the section cited above as three med-techs did not have proof of annual medication training which poses a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 29-AS-20220321114529
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/22/2023
Section Cited
CCR
87411(c)(1)
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87411 Personnel Requirements - General (c)(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
This requirement is not met as evidenced by:
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The Business Office Manager agrees to submit proof S1, S2, S3, S4, S5, and S6 have proof of current first aid training by 08/22/2023.
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Based on record review, the licensee failed to comply with the section cited above as six out of six files reviewed did not have proof of first aid training which poses a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 7
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
03/21/2022 and conducted by Evaluator Kasandra Lopez
COMPLAINT CONTROL NUMBER: 29-AS-20220321114529

FACILITY NAME:SAGE MOUNTAIN SENIOR LIVINGFACILITY NUMBER:
565802462
ADMINISTRATOR:JILL FORDFACILITY TYPE:
740
ADDRESS:3499 GRANDE VISTA DRTELEPHONE:
(805) 375-0695
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91320
CAPACITY:145CENSUS: 109DATE:
08/01/2023
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Jennifer MillerTIME COMPLETED:
05:05 PM
ALLEGATION(S):
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Unqualified staff cooking
INVESTIGATION FINDINGS:
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Allegation: Unqualified staff cooking

The allegation alleges when the facility is short staffed, staff who are not food handler certified are directed to cook the resident meals. A facility job description was reviewed for Cooks and Culinary Directors. A Cook is required to obtain a Food Handlers permit as required by state regulations and have a one year minimum experience in food service. Current Title 22 Regulations do not require staff to have a Food Handlers permit. The job description for the Culinary Director is three years experience in food service and management and a current serve/safe certification.

During a previous visit on 07/26/2022, the LPA met with Culinary Director, at that time Michael Tabada. Mr. Tabada provided proof of a current Serve/Safe Certification and met other requirements. Staff interviewed during this visit revealed only qualified staff were cooking resident meals. Report continued on LIC 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 29-AS-20220321114529
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: 08/01/2023
NARRATIVE
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During the inspection on 02/16/2023, the LPA obtained proof the Culinary Director at that time had current Serve Safe/Food Handler certificate and met other requirements. Since the complaint was filed, the facility has a new management company with new job descriptions.

Based on the information obtained, there is in sufficient evidence to support the allegation of unqualified staff cooking occurred. 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 PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 7