565802462-6-17-2024-29-AS-KLOZ-D6P2CC-20240628171626

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802462
Report Date: 06/17/2024
Date Signed: 06/17/2024 05:19:59 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
06/19/2023 and conducted by Evaluator Esther Cortez

COMPLAINT CONTROL NUMBER: 29-AS-20230619203034

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: 95	DATE:	06/17/2024
		UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Eugenia Taylor-Director Of Nursing		TIME COMPLETED:	05:20 PM

ALLEGATION(S):

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Staff did not safeguard resident's personal supplies
Staff did not provide resident / resident's authorized person copies of requested records

INVESTIGATION FINDINGS:

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At 9:50 a.m. Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced subsequent complaint investigation visit regarding the above allegations. The LPA met with Director of Nursing Eugenia Taylor and explained the reason for the inspection.

On 06/21/2023, from 10:26 a.m. to 3:30 p.m., LPA KaSandra Lopez conducted an initial complaint inspection at the facility. LPA Lopez met with Business Office Manager Jennifer Miller and informed her of the reason for the visit. Between 10:15 a.m. and 11:16 a.m., the LPA reviewed facility records and requested copies of pertinent records. During the visit, the LPA also conducted an interview with Staff #1 (S1), observed R1’s apartment and the requested records were reviewed. LPA Lopez determined further investigation was needed and notified the facility that Community Care Licensing Division (CCLD) Investigations Branch (IB) Investigator Olivia Spindola will be investigating the Personal Rights allegations.
Report will continue on LIC9099-C (2ND PAGE).

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024

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-20230619203034

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 06/17/2024

NARRATIVE

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On 07/07/2023 LPA Lopez conducted interviews with two staff members between 11:55 AM and 1:54 PM. On 05/07/2024 LPAs Esther Cortez and Sandra Urena conducted interviews and observed resident rooms. During today's visit LPA Cortez conducted a record review and staff interview.

Staff did not safeguard resident's personal supplies.
On the allegation that Staff did not safeguard resident's personal supplies, the reporting parties concern is that a family member and the hospice nurse witnessed staff #2 (S2) come into Resident’s #1 (R1’s) room, take incontinence supplies and leave. To investigate the allegation, interviews were conducted. Interviews with S2, conducted on 07/07/23, revealed that S2 admitted to taking some of R1’s incontinent supplies and stated they knew it was wrong, and that they were in a hurry to assist other residents who needed to be changed. The staff stated a home health nurse observed them take the supplies and said they returned them when confronted. The staff stated this happened only one time. There is sufficient evidence to support the allegation of Staff did not safeguard resident's personal supplies. Therefore, the above allegation is deemed Substantiated at this time.

Staff did not provide resident / resident's authorized person copies of requested records.
On the allegation that Staff did not provide resident / resident's authorized person copies of requested records, the reporting parties concern is that on numerous occasions R1’s records were requested by the resident and or resident’s authorized person and not provided. It was further reported that when the records were provided, they were not complete, specifically documentation of R1’s fall on 12/30/22 was not provided along with other documents. To investigate the allegation, record review and interviews were conducted. Information obtained revealed that on 02/01/2023 (previous) Administrator Jill Ford received and signed a request for R1’s records, including but not limited to personal and clinical records to be release to R1’s authorized person. On 02/27/2023, the facility received a second medical record request from R1’s authorized person. In addition, information obtained revealed that R1’s authorized person made contact with Administrator Jill Ford via email regarding R1’s records request on 03/26/23, 04/02/23, 04/21/23, 05/06/23, 05/07/23, 05/14/23 and on 05/15/23. On or about 05/15/23, R1’s records were issued to R1’s authorized person, however it was reported to the interim Administrator Julius Osorio on 05/31/23 that the records were incomplete, particularly regarding a fall R1 sustained on 12/30/22.

Report will continue on LIC9099-C (3RD PAGE).

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230619203034

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 06/17/2024

NARRATIVE

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In 2023 Sage Mountain Senior living transitioned from Milestone management company to Agemark management company. Interview with Julius Osorio, who was the interim Administrator during June of 2023, revealed that they received notification from R1’s authorized person on 05/31/23 via email that R1’s records were incomplete, however all the records that were provided were the same records Agemark had on file. Osorio revealed that R1’s authorized person had been informed Agemark would not have access to digital records once they took over and records would need to be requested through Milestone. It was further revealed that Osario did not verify if R1’s authorized person had received the requested missing documentation as they assumed Milestone would be handling it through their team. Record review revealed that there was no record of an incident report completed for R1’s fall on 12/30/22. Based on the information obtained, the Department found sufficient evidence to support the allegation, Staff did not provide resident / resident's authorized person copies of requested records. Therefore, the allegation is deemed Substantiated at this time.

Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D).

Exit interview conducted, appeal rights discussed, and a copy of this report issued.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 29-AS-20230619203034

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/17/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/28/2024 Section Cited CCR 87217(b)	1 2 3 4 5 6 7	87217(b) Safeguards for Resident Cash, Personal Property, and Valuables Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff.	1 2 3 4 5 6 7	Administrator will submit a plan to properly safeguard residents' property as well as provide staff training regarding safeguarding residents' personal property. Submit to CCL by 06/28/2024.
	8 9 10 11 12 13 14	Based on interviews S2 admiited to taking R1's incontinence supplies which posed a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
Type B 06/28/2024 Section Cited CCR 87506(c)(1)	1 2 3 4 5 6 7	87506(c)(1) The licensee shall be responsible for storing active and inactive records...The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative. This requirement was not	1 2 3 4 5 6 7	Administrator agreed to submit a statement of understanding of regulation 87506 and will make a plan on how to follow up on record requests in a timely manner and notify resident or resident's authorized person if they do not have the records, will submit to CCL by 6/28/24.
	8 9 10 11 12 13 14	met as evidenced by: Based on interviews, the licensee did not comply with the section cited above when the facility did not make complete records available to the resident or representative, which poses a potential health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14	Administrator will also follow up on the record request for R1.

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 Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024

LIC9099 (FAS) - (06/04)

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