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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802462
Report Date: 06/18/2024
Date Signed: 06/18/2024 06:00:49 PM


Document Has Been Signed on 06/18/2024 06:00 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:BETSY MCCOYFACILITY TYPE:
740
ADDRESS:3499 GRANDE VISTA DRTELEPHONE:
(805) 375-0695
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91320
CAPACITY:145CENSUS: 95DATE:
06/18/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
05:00 PM
MET WITH:Betsy MccoyTIME COMPLETED:
06:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management Deficiency visit in conjunction with an initial 10-day complaint visit (CC #29-AS-20230619203034). LPA met with Executive Director Betsy Mccoy. The purpose of this visit is to issue citations for deficiencies observed during the complaint investigation which were not related to the complaint allegations.

On 12/30/2022, R1 sustained a fall. An unknown staff called R1’s resident representative and informed them of R1’s fall and told them although R1 was in some pain from the fall, R1 was okay. Staff notified the business manager, who described the incident as R1 slipped off R1’s chair. There was no record of an incident report completed. On 01/05/2023, hospital personnel diagnosed R1 with a displaced left clavicle, a fractured left rib, and left shoulder dislocation with severe bruising to the area. The injuries were determined to be the result of the 12/30/2022 fall.

Citation issued, exit interview, appeal rights given.
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:
DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024
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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Document Has Been Signed on 06/18/2024 06:00 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 LIVING
FACILITY NUMBER: 565802462

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/21/2024
Section Cited
CCR
87211(a)(1)(B)

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87211(a)(1)(B) Reporting Requirements. The licensee shall send a written report, within seven days, to the licensing agency and the person responsible for the resident when a resident incurs any serious injury while under facility supervision. This requirement is not met as evidenced by:
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The licensee will submit a plan describing how you will ensure reporting requirements are followed. Submit proof to CCL by 06/21/24.
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Based on interviews and records review, the licensee did not comply with the section cited above. Licensee did not submit an incident report for R1’s fall in which R1 complained of pain to shoulder, which resulted in injuries not diagnosed until 01/05/2023, which posed 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: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:
DATE: 06/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024
LIC809 (FAS) - (06/04)
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