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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565802462
Report Date: 06/18/2024
Date Signed: 06/18/2024 06:02:27 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 LIVINGFACILITY NUMBER:
565802462
ADMINISTRATOR:JANELLE LOPEZFACILITY TYPE:
740
ADDRESS:3499 GRANDE VISTA DRTELEPHONE:
(805) 375-0695
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91320
CAPACITY:145CENSUS: 95DATE:
06/18/2024
UNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Betsy Mccoy-Executive DirectorTIME COMPLETED:
06:10 PM
ALLEGATION(S):
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Resident sustained a fracture while in care.
Staff did not respond to resident’s call for assistance in a timely manner.
Staff did not seek medical assistance for resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Esther Cortez conducted a subsequent complaint visit to deliver findings for the above allegations. LPA met with Executive Director Betsy Mccoy and explained the reason for the visit.

On 06/19/2023, the Department received a complaint alleging Neglect/Lack of Care and Supervision regarding Resident #1 (R1). R1 sustained a fracture while in care, staff did not respond to R1’s call for assistance in a timely manner, and staff did not seek medical assistance for R1. The complaint was referred to the Community Care Licensing (CCL) Investigations Branch (IB) and assigned to Investigator Olivia Spindola. The case was also referred to the Department’s Program Clinical Consultant (PCC) for review.

Report will continue on LIC9099-C. (2nd page.)
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 9
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 LIVINGFACILITY NUMBER:
565802462
ADMINISTRATOR:JANELLE LOPEZFACILITY TYPE:
740
ADDRESS:3499 GRANDE VISTA DRTELEPHONE:
(805) 375-0695
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91320
CAPACITY:145CENSUS: DATE:
06/18/2024
UNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:BETSY MCCOY TIME COMPLETED:
06:10 PM
ALLEGATION(S):
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Resident sustained pressure injuries due to staff neglect
Staff did not keep the facility free from odor.
Staff did not ensure that resident's soiled laundry was cleaned.


INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Esther Cortez conducted a subsequent complaint visit to deliver findings for the above allegations. LPA met with Executive Director Betsy Mccoy and explained the reason for the visit.

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. On 07/07/2023, LPA Lopez conducted a subsequent visit and conducted two staff interviews between 11:55 AM and 1:54 PM.
Report will continue on LIC9099-C (2ND PAGE).

Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 2 of 9
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: 06/18/2024
NARRATIVE
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On 05/07/2024, LPAs Esther Cortez and Sandra Urena conducted an inspection at the facility and conducted interviews and observed resident rooms between 10:00 AM and 4:30 PM. On 06/17/2024, LPA Cortez conducted a subsequent visit, conducted a record review and staff interview. During today's visit LPA Cortez conducted staff interviews and obtained pertinent documents.

On 06/19/2023, the Department received a complaint alleging Resident #1 (R1) sustained pressure injuries due to staff neglect. The reporting parties concern is that R1 developed a stage III pressure injury at the facility prior to receiving hospice care.

According to the facility file documents reviewed, R1 was admitted to the facility on 01/25/2020. Per the facility preplacement appraisal, R1 used a walker/wheelchair and required assistance for transferring, bathing, toileting, and medication management. Per the Physician’s report, dated 01/20/2020, R1 did not have a history of skin condition or breakdown. Per the Physician's report, dated 11/24/2020, R1 had listed diagnoses of congestive heart failure, muscle weakness, hypertension, low back pain and hypothyroidism. R1 was on a low-sodium diet, had bowel and bladder impairment, and required assistance for all activities of daily living, except feeding self and did not have history of skin condition or breakdown.

Based on the review of the Milestone semiannual assessment, dated 07/09/2021, R1 required one (1) person or standby assist 8x daily, required staff assistance with showers 2x weekly, required frequent incontinence assist 3x weekly, under medication management required skin treatment 2x daily, and required coordination of care with Home Health 1x weekly. Per the Service Agreement, dated 07/09/2021, effective 01/21/2020 R1 required bathing assist twice a week every Monday and Friday, and assistance with dressing daily; effective 04/21/2020, R1 required LVN to assess skin weekly to monitor skin integrity and progress, Divine Home Health to provide wound care to affected area on Mondays, Wednesdays, and Fridays, LVN/Med Tech to provide skin treatment am and pm as per MD orders, and caregivers were to provide R1 with assistance with transfers through the day; effective 07/09/2021 R1 required staff assist with toileting throughout the NOC hours, staff to check frequently to ensure R1 is clean and dry, and R1 required assistance by staff to toilet throughout the day and overnight hours.

Report will continue on LIC9099-C (3RD PAGE).
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
LIC9099 (FAS) - (06/04)
Page: 3 of 9
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: 06/18/2024
NARRATIVE
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Home health records and hospice care records were subpoenaed and reviewed. The review of home health records revealed R1 was receiving home health services from approximately December 2020 through December 2021, for various health conditions, including stage one and stage two pressure injuries. Records reviewed did not reveal the presence of any stage three pressure injuries during this time. On December 23, 2021, R1 was discharged from home health with no pressure injuries. Record review of the home health records also did not reveal any indication of neglect from facility staff during that time.

On January 6, 2022, R1 was seen by their primary care physician who diagnosed R1 with buttocks wound and ordered home health services for treatment. Records did not indicate any staging of the wound.

Hospice records reviewed revealed, on January 25, 2022, R1 elected to receive hospice care services. A review of the January 25, 2022, comprehensive nursing assessment indicated revealed R1 had two stage three pressure injuries and one stage two pressure injuries and received treatment.

Although the allegation of Resident sustained pressure injuries due to staff neglect including a stage 3 pressure injury prior to the start of hospice services may have occurred. There is insufficient evidence to support the allegation. Therefore, the allegation is deemed unsubstantiated at this time.

On the allegations that Staff did not keep the facility free from odor and Staff did not ensure that resident's soiled laundry was cleaned, it is the reporting parties concern that there was a urine smell that was coming from Resident #1’s (R1’s) closet due to soiled laundry left in their hamper in plastic bags. To investigate the allegation, interviews and physical plant tours were conducted. Staff Interviews conducted revealed that R1’s room did have an odor, however R1's room and laundry was constantly clean and laundered. Majority of the resident interviews conducted by LPA Cortez revealed that the facility smells fine and that they have not smelled any odor of urine coming from the rooms. In addition, seven (7) of (seven) 7 residents interviewed on 05/07/2024 revealed that laundry gets done once a week, and soiled laundry has not been left behind. On 06/21/2023 LPA Lopez did not detect any scents or smell of urine in R1's previous apartment. LPA Cortez did not detect any urine odor from any of the rooms or common areas toured during their visits at the facility. Although the allegation may have happened or is valid, based on interviews and observations, the above allegations are deemed unsubstantiated at this time.
Exit interview conducted. A copy of the report and appeal rights were provided.
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
LIC9099 (FAS) - (06/04)
Page: 4 of 9
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: 06/18/2024
NARRATIVE
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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. On 07/07/2023, LPA Lopez conducted a subsequent visit and conducted two staff interviews between 11:55 AM and 1:54 PM.

On 07/19/2023, from approximately 12:00 p.m. to 1:45 p.m., Investigator Spindola conducted interviews with facility staff and residents; on 08/18/2023, at approximately 3:00 p.m., with R1’s resident representative; on 09/06/2023, from approximately 12:50 p.m. to 4:45 p.m., with facility staff; and on 09/18/2023, at 10:00 a.m., with R1’s resident representative. In addition, Investigator Spindola reviewed Los Robles Regional Medical Center (LRRMC) medical records, physician reports and records, and other facility file documents related to R1.

On 05/07/2024, LPAs Esther Cortez and Sandra Urena conducted an inspection at the facility and conducted interviews and observed resident rooms between 10:00 AM and 4:30 PM. On 06/17/2024, LPA Cortez conducted a subsequent visit, conducted a record review and staff interview. During today's visit LPA Cortez conducted staff interviews and obtained pertinent documents.

According to the facility file documents reviewed, R1 was admitted to the facility on 01/25/2020. Per the facility preplacement appraisal, R1 used a walker/wheelchair and required assistance for transferring, bathing, toileting, and medication management. Per the Physician's report, dated 11/24/2020, R1 had listed diagnoses of congestive heart failure, muscle weakness, hypertension, low back pain and hypothyroidism. R1 was on a low-sodium diet, had bowel and bladder impairment, and required assistance for all activities of daily living, except feeding self.

Based on the review of the updated facility service plan dated 5/12/2020, caregivers were instructed to monitor R1 for shortness of breath, increased perspiration, radiating pain, and nausea, monitor for signs and symptoms of bleeding, and report to LVN/Med tech on duty. Caregivers were instructed to notify the nurse or med tech for signs and symptoms of low blood sugar. Caregivers to assist with toileting, dressing, bathing, and Neighbor Care Home Health transferring. Report will continue on LIC9099-C. (3rd page.)
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
LIC9099 (FAS) - (06/04)
Page: 5 of 9
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: 06/18/2024
NARRATIVE
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The LVN/Med tech to provide medication management (medications and oxygen), skin treatment daily as ordered by the doctor, LVN to assess skin weekly, home health to provide wound care to affective area on Monday, Wednesday, and Friday. Caregivers to alert fall risks as needed, the interventions of fall prevention were not indicated in the service plan.

The investigation revealed that on 12/30/2022, R1 sustained a fall. The facility staff did not obtain medical care. There was no evidence that the facility monitored the resident closely for signs of pain and injury related to the 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, during the early hours of the morning R1 experienced severe vomiting and used their call button to request staff assistance. However, when staff did not come to R1’s room to assist, R1 dialed 911 and was transported to LRRMC where R1 was diagnosed with a Norovirus infection and a displaced left clavicle, a fractured left rib, and left shoulder dislocation with severe bruising to the area.

A review of the LRRMC medical records indicated that R1 was admitted on 01/05/2023 with chief complaint of nausea and vomiting since midnight. R1 stated has thrown up 3-4 times… also has left shoulder pain/deformity and had a mechanical fall out of chair 2 days ago in which R1 hit left shoulder. The admitting diagnosis included acute cystitis without hematuria, bilateral leg sores, chronic left shoulder dislocation, acute left clavicle fracture and left first rib fracture secondary to mechanical fall, gastroenteritis, Norovirus. Bruising to the left shoulder was also noted. On 01/10/2023, R1 was discharged with a shoulder sling to Thousand Oaks Post-Acute Care and advised to follow up with a shoulder specialist, pain control with Norco and Morphine.

On the allegation “Resident sustained a fracture while in care” - The investigation revealed that on 12/30/2022, R1 sustained a fall. An unknown facility staff called R1’s resident representative and informed them of R1’s’s fall and told them although R1 was in some pain from the fall, R1 was okay. On 01/05/2023, R1 went to the Los Robles Regional Medical Center (LRRMC) due to severe vomiting. LRRMC medical personnel determined that R1’s vomiting was due to a Norovirus infection. Report will continue on LIC9099-C. (4th page.)
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
LIC9099 (FAS) - (06/04)
Page: 6 of 9
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: 06/18/2024
NARRATIVE
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LRRMC also determined R1 had a displaced left clavicle, a fractured left rib, and left shoulder dislocation with severe bruising to the area. Based on witnesses’ statements and medical records, the Department found sufficient evidence to support the allegation of a lack of supervision resulted in R1 sustaining a fracture while in care. Therefore, the allegation is deemed Substantiated at this time.

On the allegation “Staff did not respond to resident’s call for assistance in a timely manner” – The investigation revealed that on 01/05/2023, during the early hours of the morning, R1 experienced severe vomiting. R1 requested assistance using their call button. However, when staff did not come to R1’s room to assist, R1 dialed 911 and was transported to LRRMC where R1 was diagnosed with a Norovirus infection and a displaced left clavicle, a fractured left rib, and left shoulder dislocation with severe bruising to the area. Based on witnesses’ statements and medical records, the Department found sufficient evidence to support the allegation of a lack of supervision resulted in staff not responding to R1’s call for assistance in a timely manner. Therefore, the allegation is deemed Substantiated at this time.

On the allegation “Staff did not seek medical assistance for resident” - The investigation revealed that on 12/30/2022, R1 sustained a fall for which the facility staff did not obtain medical care, and on 01/05/2023, when R1 called 911 for emergency medical assistance after the facility staff failed to come to R1’s room when R1 called using their call button. LRRMC diagnosed R1 with a Norovirus infection and a displaced left clavicle, a fractured left rib, a left shoulder dislocation with severe bruising to the left shoulder area. Based on witnesses’ statements and medical records, the Department found sufficient evidence to support the allegation of a lack of supervision resulted in staff not seeking medical assistance for R1. Therefore, the allegation is deemed Substantiated at this time.

A $500 immediate civil penalty is assessed today. The ED, Betsy Mccoy was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f).

A $250 immediate civil penalty is assessed today due to a repeat violation of 87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities. The facility was previously cited on 02/01/2024.

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 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
LIC9099 (FAS) - (06/04)
Page: 7 of 9
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: 06/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/19/2024
Section Cited
HSC
1569.312(a)
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§1569.312(a) Basic services requirements.
Basic services shall at a minimum include: (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 how you will ensure appropriate care and supervision to meet the needs of residents. Submit to CCL by 06/19/2024.
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Based on interviews & records review, the licensee did not comply with the section cited above. Due to a lack of supervision by facility staff, R1sustained a fracture while in care, which posed an immediate health and safety risk to residents in care.
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Type A
06/19/2024
Section Cited
CCR
87468.2(a)(4)
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87468.2(a)(4)residents…shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.This requirement is not met
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Licensee will submit a plan how you will ensure residents receive assistance in a timely manner. Submit to CCL by 06/19/2024.
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as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above.Staff did not respond to R1’s call for assistance in a timely manner, which posed an immediate 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
LIC9099 (FAS) - (06/04)
Page: 8 of 9
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: 06/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/19/2024
Section Cited
CCR
87465(j)
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87465(j) In all facilities licensed for sixteen (16) persons or more, one or more employees shall be designated as having primary responsibility for assuring that each resident receives needed first aid and needed emergency medical services… This requirement is not met
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Licensee will submit a plan how you will ensure residents receive timely medical assistance. Submit to CCL by 06/19/2024.
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as evidenced by: Based on interviews & records review, the licensee did not comply with the section cited above. Facility staff did not seek medical assistance for R1 on 12/30/22 and 01/05/23, which posed an immediate 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
LIC9099 (FAS) - (06/04)
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