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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565802462
Report Date: 03/30/2022
Date Signed: 03/30/2022 05:42:19 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,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/26/2020 and conducted by Evaluator Kelly Dulek
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20201026131122
FACILITY NAME:SAGE MOUNTAIN SENIOR LIVINGFACILITY NUMBER:
565802462
ADMINISTRATOR:JADE ALMA-HARRISFACILITY TYPE:
740
ADDRESS:3499 GRANDE VISTA DRTELEPHONE:
(805) 375-0695
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91320
CAPACITY:145CENSUS: 102DATE:
03/30/2022
UNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Jill Ford, Executive DirectorTIME COMPLETED:
04:55 PM
ALLEGATION(S):
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Due to lack of care and supervision, resident developed a pressure injury while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint visit to the above noted facility. The purpose of the visit is to conclude an investigation regarding the above allegation initiated by LPA Rosales on 10/27/2020. LPA met with Senior Executive Director Jill Ford and explained the reason for the visit. Entrance interview conducted.

On 10/26/2020, the Department received a complaint which alleged that due to lack of care and supervision, Resident #1 (R1) had sustained a Stage IV pressure injury while in care and the facility continued to retain this resident without informing nor requesting an exception from CCLD to retain this resident. This allegation was referred to CCLD Investigation Branch (IB) on 10/26/2020 and assigned to Investigator Christine Ferris.

On 10/27/2020, due to the situation surrounding Coronavirus-19 (COVID-19) and to implement mitigation measures, LPA Rosales conducted an initial virtual complaint from 11:04AM to 11:43AM. LPA Rosales virtually
REPORT CONTINUED ON LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: TELEPHONE:
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE:
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022
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 6
Control Number 29-AS-20201026131122
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: SAGE MOUNTAIN SENIOR LIVING
FACILITY NUMBER: 565802462
VISIT DATE: 03/30/2022
NARRATIVE
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toured the facility with Administrator and requested pertinent staff and resident documents. On 11/03/2020, 11/04/2020 and 11/05/2020, Investigator Ferris conducted telephone interviews with pertinent parties. On 11/13/2020, Investigator Ferris conducted in person staff interviews at the facility. Investigator Ferris then reviewed R1’s medical records and other pertinent documentation obtained from the facility. The following was concluded:

Documents reviewed revealed that R1 was admitted to the facility on 02/06/2020. At that time, although R1’s physician’s report indicated “history of skin breakdown” no open wounds were noted upon admission. In fact, Home Health report dated 02/11/2020, indicated “blanchable redness on bilateral buttocks. Caregiver, (family member), Assisted Living LVN all notified.” Instruction was provided to the caregivers on changing R1’s position regularly, managing incontinence timely, and keeping the skin clean and dry. By 02/14/2020, Home Health records indicate “patient observed with dressing on sacrum area. When dressing removed, observed open wound on sacrum…caregiver, (family member,) Assisted Living LVN all notified. Caregiver stated she had the nurse look at the area this am and he applied the dressing.” By 02/18/2020, the wound was noted “much larger and deteriorating.” On 02/20/2020, the wound was recorded as a Pressure Ulcer Stage IV. Interviews conducted during the course of the investigation revealed that facility staff were aware R1 had developed a “bad pressure injury” prior to being placed on hospice. Record review revealed that R1 was placed on hospice effective 02/21/2020, although the pressure injury was noted a week earlier on 02/14/2020. Based on all information obtained, the above allegation “due to lack of care and supervision, resident developed a pressure injury while in care” is deemed SUBSTANTIATED at this time.

A $500 immediate civil penalty is assessed today. The Senior Executive Director was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(f).

Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D)
Exit interview conducted and civil penalty issued. A copy of this report and appeal rights were issued via email.
SUPERVISOR'S NAME: TELEPHONE:
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE:
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20201026131122
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: SAGE MOUNTAIN SENIOR LIVING
FACILITY NUMBER: 565802462
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/06/2022
Section Cited
HSC
1569.312(a)
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1569.312(a) Basic service requirements. Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2
This requirement is not met as evidenced by:
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LIcensee will submit a plan to provide proper level of care and supervision to ensure residents' needs are met. Plan must be submitted to CCL on or before 04/06/2022.
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Based on interviews and records review, the licensee did not comply with the section cited above. Licensee did not provide adequate care and supervision to R1 which attributed to R1 sustaining pressure injuries not reported and not cared for, which posed an immediate health and safety risk to residents in care.
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CCR
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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: TELEPHONE:
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE:
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/26/2020 and conducted by Evaluator Kelly Dulek
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20201026131122

FACILITY NAME:SAGE MOUNTAIN SENIOR LIVINGFACILITY NUMBER:
565802462
ADMINISTRATOR:JADE ALMA-HARRISFACILITY TYPE:
740
ADDRESS:3499 GRANDE VISTA DRTELEPHONE:
(805) 375-0695
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91320
CAPACITY:145CENSUS: 102DATE:
03/30/2022
UNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Jill Ford, Executive DirectorTIME COMPLETED:
04:55 PM
ALLEGATION(S):
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Facility did not provide adequate care and supervision, which resulted in R2’s death
Facility is retaining a resident with active tuberculosis
Facility has scabies outbreak
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint visit to the above noted facility. The purpose of the visit is to conclude an investigation regarding the above allegation initiated by LPA Rosales on 10/27/2020. LPA met with Senior Executive Director Jill Ford and explained the reason for the visit. Entrance interview conducted.

On 10/26/2020, the Department received a complaint which alleged the facility did not provide adequate care and supervision to Resident #2 (R2) resulting in R2’s death. This allegation was referred to CCLD Investigation Branch (IB) on 10/26/2020 and assigned to Investigator Christine Ferris.

On 10/27/2020, due to the situation surrounding Coronavirus-19 (COVID-19) and to implement mitigation measures, LPA Rosales conducted an initial virtual complaint from 11:04AM to 11:43AM. LPA Rosales virtually toured the facility with Administrator and requested pertinent staff and resident documents. On 11/03/2020,
REPORT CONTINUED ON LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: TELEPHONE:
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE:
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20201026131122
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: SAGE MOUNTAIN SENIOR LIVING
FACILITY NUMBER: 565802462
VISIT DATE: 03/30/2022
NARRATIVE
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11/04/2020 and 11/05/2020, Investigator Ferris conducted telephone interviews with pertinent parties. On 11/13/2020, Investigator Ferris conducted in person staff interviews at the facility. Investigator Ferris then reviewed R2’s medical records and other pertinent documentation obtained from the facility. The following was concluded:

Documents reviewed revealed that R2’s care plan contained service plan for cardiac alerts to be performed by care staff and included information on signs and symptoms to observe R2 for and to alert LVN/Med Aide if observed. Additionally, R2’s care plan indicated presence of a pacemaker alert since 01/18/2019. On 10/09/2020, a faxed copy of R2’s death report was received in the Woodland Hills Regional Office. Death report indicated on 09/19/2020, R2 was admitted to the hospital due to shortness of breath and chest pain. R2 returned to the facility on 09/30/2020. Record review revealed R2’s physician’s report was updated upon discharge from the hospital on 09/30/2020, indicated R2 had a diagnosis of end stage heart disease. R2 was then admitted to hospice on 10/01/2020 with a diagnosis of Congestive Heart Failure/Atrial Fibrillation. R2 had a Do Not Resuscitate (DNR) order in place as of 10/01/2020. R2’s death report indicated on 10/02/2020 at 5:00PM, R2 was noted unresponsive and unable to obtain vital signs. R2 was pronounced dead on 10/02/2020 at 5:05PM by hospice care staff. Death report for R2 indicated immediate cause of death was congestive heart failure with underlying causes listed as atrial fibrillation and hypertension. Based on all information obtained, there is insufficient evidence to support the allegation, therefore the above allegation “facility did not provide adequate care and supervision, which resulted in R2’s death” is deemed UNSUBSTANTIATED at this time.

Additionally, the complaint the Department received on 10/26/2020 contained an allegation that the “facility is retaining a resident with active tuberculosis (TB).” LPA Dulek had received a phone call from Administrator Jade Alma-Harris on 10/20/2020 indicating Resident #3 (R3) had recently moved into the facility. Upon admission, R3’s physician’s report indicated no evidence of TB, but did not indicate a date a TB test was administered. Administrator Alma-Harris confirmed R3 had resided at another RCFE prior to moving into the facility and had no known TB exposure. Due to the physician’s report missing a TB test date, the resident had an on-site visit from a mobile doctor. The doctor took a chest x-ray and the results appeared questionable, so the doctor conducted a blood test. Results of the blood test indicated a TB infection. Ms. Alma-Harris contacted Ventura County Public Health, who directed the facility to retest R3, as R3 had no known TB
Report Continued on LIC 9099-C
SUPERVISOR'S NAME: TELEPHONE:
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE:
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20201026131122
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: SAGE MOUNTAIN SENIOR LIVING
FACILITY NUMBER: 565802462
VISIT DATE: 03/30/2022
NARRATIVE
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exposure and the result may be due to latent TB infection or a false positive. The following day, on 10/21/2021, a doctor conducted additional testing and confirmed R3 did not have any evidence of active TB. LPA Dulek reviewed records provided for R3 and confirmed R3 had a negative TB test on 10/21/2020. Based on all information obtained, there is insufficient evidence to support the allegation, therefore the above allegation “facility is retaining a resident with active tuberculosis” is deemed UNSUBSTANTIATED at this time.

The complaint also contained an allegation that the facility has a scabies outbreak. LPA Dulek, along with Executive Director Jill Ford reviewed electronic medical records for 28 of 28 residents residing in the Memory Care unit during the time period the complaint was received. Although many resident medical records and care notes did indicate residents had a rash, there was no indication of a scabies diagnosis for any of the 28 resident records reviewed. Interview with Ventura County Public Health (VCPH) indicated there were no reports to VCPH at the time of the allegation. VCPH nurse indicated Permetherin cream is used to treat scabies infections and is only prescribed for scabies. 3 of the 28 resident records reviewed indicated Peremethrin cream was prescribed to the resident, however all 3 of 3 residents’ physicians indicated an alternate diagnosis. One indicated a diagnosis of dermatitis, one indicated a mild rash, and the other indicated primary care physician “does not believe the resident has scabies.” Based on record review, although the allegation may be valid, at this time, there is insufficient evidence to support the allegation. Therefore, the allegation that “facility has a scabies outbreak” is deemed UNSUBSTANTIATED at this time.

Exit interview conducted. A copy of the report was provided via email.
SUPERVISOR'S NAME: TELEPHONE:
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE:
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6