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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802462
Report Date: 06/25/2024
Date Signed: 06/25/2024 11:09:34 AM


Document Has Been Signed on 06/25/2024 11:09 AM - 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: 97DATE:
06/25/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:58 AM
MET WITH:Betsy MccoyTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Esther Cortez conducted a Case Management - Incident visit. LPA met with current Executive Director (ED) Betsy Mccoy and explained the reason for the visit.

On 06/24/2024, the facility submitted an Unusual Incident/Injury Report (LIC624) pertaining to Resident #1 (R1) and Resident #2 (R2). It was reported that on 06/21/2024, R1 reported to the ED that their credit card was stolen on 06/20/2024 and during the facilities investigation, the ED was informed that R2's credit card was also stolen.

During today's inspection, the LPA conducted an interviewed with the ED and obtained pertinent documents. According to the ED, the facility has a theft and loss program in place and are currently conducting an investigation to assist the residents. ED also stated that she was informed police reports were made by the residents or resident's family members. Additionally, the ED revealed that she receive information that R2's credit card information was stolen and not the actual credit card, outside of the facility.

If further investigation is required, the LPA will return at a later date. Exit interview conducted and report reviewed. A copy of the report was provided.
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:
DATE: 06/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/25/2024
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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