565802462-11-15-2023-29-AS-ECAS-CXM3PN-20231115172551

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565802462
Report Date: 11/15/2023
Date Signed: 11/15/2023 05:27:46 PM

Document Has Been Signed on 11/15/2023 05:27 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

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: 102	DATE:	11/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Sherry Nazari		TIME COMPLETED:	05:40 PM

NARRATIVE

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Licensing Program Analysts (LPA’s) Elsie Campos, and Zabel Chochian arrived at the facility unannounced to conduct a required annual visit at 9:20 a.m. The LPA's were greeted by staff and Administrator Sherry Nazari and informed them of the reason for the visit.

The LPA’s and the Maintenance Director began the tour of the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: The LPAs began the inspection in the kitchen/food service area at 10:55 a.m. Knives and cleaning supplies are stored inaccessible. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. LPA's did not observe a supply of emergency food and water supply. COMMON AREAS: At the time of the visit, units designated for assisted living residents are on all four floors and there is a separate unit on the second floor designated for memory care residents. The LPA’s toured all four floors and common spaces in both the assisted living and memory care unit. Activity rooms and common spaces were clean and in good repair. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detector were last inspected on 7/11/23 by COBOS Fire & Safety. The fire extinguishers were fully charged and were last serviced 07/11/2023 by COBOS Fire & Safety. The LPA's observed required postings near the mail room hallway. The LPA's observed the stairwells and they each had an emergency evacuation chair. At approx. 11:40 a.m. – LPA’s observed multiple residents doing an activity with the activity’s director in the 1^st floor common area. BEDROOMS: At approx. 11:45 a.m. the LPA's observed twelve (12) randomly selected resident bedrooms, which were furnished appropriately with linens, appropriate furnishings, and sufficient lighting. Bedroom #319 was observed to have temperature at 83 degrees F. Interview with resident and staff revealed that this room has had consistent issues with temperature adjustment and room was too hot for resident. ** Continued on LIC 809-C**

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

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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Document Has Been Signed on 11/15/2023 05:27 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
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: 11/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.695(a)(2)

Other Provisions

(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as the faciltiy did not have a supply of emergency food and water which poses a potential health and safety risk to persons in care.
	POC Due Date: 11/24/2023
	Plan of Correction
1 2 3 4	The Licensee agreed to do the following: 1. Obtain a supply of emergency food and water and store away from day to day food and water supplies. Provide proof to CCL no later than the POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/15/2023 05:27 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
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: 11/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)(1)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above as in bedroom 319 did not have a comfortable temperature for the resident, based observation room #241 had a strong odor emitting from the bathroom and carpet next the closet which poses a potential health and safety risk to persons in care.
	POC Due Date: 11/24/2023
	Plan of Correction
1 2 3 4	The Licensee agreed to the following: 1. Adjust temerpature and maintan consisent comfortable temeprature for resident in room 319. Record temps for 5 days and provide proof to CCL no later than POC date. 2. Clean carpet and bathroom and provide proof to CCL.

Type B

Section Cited

CCR

87303(e)(6)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as sink in bedroom #241 was not draining and retaining the water which poses a potential health and safety risk to persons in care.
	POC Due Date: 11/24/2023
	Plan of Correction
1 2 3 4	Licensee agreed to the following: 1. Repair sink to ensure proper drainage and provide proof to CCL no later than POC due date.

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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 11/15/2023

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Bedroom #241 had a strong odor omitting from the carpet near the closet, Bedroom #410 at approximately 2:00 p.m. still did not have lunch tray picked up. LPA’s conducted interviews while touring bedrooms with twelve (12) residents between 11:45 a.m. to 3:00 p.m The LPA's observed a sufficient supply of towels and linens. Resident pendants were tested in multiple rooms, LPA's observed staff arrive in a timely manner to assist residents. RESTROOMS: The resident restrooms appeared clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared in the private rooms. Restroom in bedroom #237 had a sticky floor and bedroom #241 restroom had a strong odor and sink was not draining the water. The hot water temperature was measured in resident rooms (#101, 111, 110, 228, 237, 241, 254, 257, 319, 343, 410, 407) ranged between 113.0– 117.5*f. (Continue to LIC809c) OUTSIDE GROUNDS: LPA's toured the outside area of the facility. LPA's observed appropriate outdoor furniture, with a covered shaded area for resident’s use. No pool on the premises. Parking is available for residents and visitors.

Due to time constraints, the LPA’s will return at a later date to complete the inspection.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

LIC809 (FAS) - (06/04)

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