565802462-6-25-2024-29-AS-KLOZ-D6P2CA-20240628171625

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802462
Report Date: 06/25/2024
Date Signed: 06/25/2024 11:12:08 AM

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: 97	DATE:	06/25/2024
		UNANNOUNCED	TIME BEGAN:	08:58 AM
MET WITH:	Betsy Mccoy-Executive Director		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Staff did not ensure that resident's toileting needs were met
Staff billed resident for services not received

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. 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. 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: 06/25/2024

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.

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: 06/25/2024

NARRATIVE

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On 06/17/2024, LPA Cortez conducted a subsequent visit, conducted a record review and staff interview. On 06/18/2024 LPA Cortez conducted staff interviews and obtained pertinent documents. During today’s visit, LPA Cortez delivered findings.

Staff did not ensure that resident's toileting needs were met.
On the allegation that Staff did not ensure that resident's toileting needs were met, the reporting parties concern is that staff did not respond timely for calls for assistance with toileting, and as a result Resident#1 (R1) would have accidents and wet themselves. To investigate the allegation, file review and interviews were conducted. Staff interviews revealed that when the facility is short staff, residents can go without showers and additionally staff interviews revealed that due to being short-staffed staff would not get to R1 timely and R1 would sometimes be wet when they got to R1. Furthermore, staff interviews revealed that if staff is busy it can take up to forty-five minutes to an hour to assist residents when they pressed their pendant. Record review conducted revealed that on numerous occasions it took longer than 30 minutes for R1’s call button to be answered. During December 2022, R1 had approximately 28 pendant calls that took approximately 30 minutes or longer to be answered, with one pendant call on December 31, 2022 taking approximately one hour and forty-two minutes to answer. Lastly, on 06/18/2024, at approximately 1:50 p.m. LPA Cortez heard staff calling for assistance from other staff to assist with a resident transfer over the radio for over twenty minutes. The staff's call for assistance went without being answered for approximately over twenty (20) minutes. Based on interviews, file review, and observation, the above allegation is deemed Substantiated at this time.

Staff billed resident for services not received.
On the allegation that Staff billed resident for services not received, the reporting parties concern is that per the admission agreement after a resident is out of the community for fifteen consecutive days a credit/refund for personal care would be issued, and staff charged Resident#1 (R1) for personal care for days R1 was at the hospital, at a skilled nursing and not in the community. It was further reported that R1 was taken to the hospital on January 5, 2023, and did not return to the facility until January 27, 2023. To investigate the allegation, record review and interviews were conducted. The LPA reviewed R1’s admission agreement which states the following: D. Adjustments to Fees or Services. 3. Absences from Sage Mountain Senior Living. If you are absent from _ Sage Mountain Senior Living for a period of fourteen (14) consecutive days or more, you will be entitled to a credit beginning on the fifteenth (15^th) day of absence in the amount set forth in Appendix A. 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: 06/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2024

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: 06/25/2024

NARRATIVE

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In addition, information obtained during the investigation revealed that R1’s authorized person had inquired with Business Office Manger Jennifer Miller on May 23^rd of 2023 via email correspondence about a credit due for the time R1 was absent from the community (1/05/2023-1/27/2023) and Miller stated they would check the dates with staff and verify if a credit was due. On May 31^st of 2023, R1’s authorized person requested an update on the credit potentially due, to which Interim Administrator at the time, Julius Osorio was cc’d on and corresponded that they would try to follow up on and provide an update. Staff interviews revealed that yes, depending on the resident’s admission agreement, if a resident would be out for a period of fourteen (14) consecutive days, residents would be entitled to a credit or refund starting on the fifteenth (15^th) day of absence. Interview conducted with Julius Osorio, revealed that they never followed up with R1’s authorized person and did not ensure they received their personal care credit they were inquiring about. Staff interviews revealed that Business Office Manager, Jennifer Miller is no longer working at the facility, and it would have been their responsibility to follow up regarding this credit/refund. Staff interviews also revealed that due to the company’s management change that took place in 2023, the new management company, Agemark, does not have access to financial records for January 2023 for residents who are no longer at the community, staff were not aware of any pending refund/credit due to R1 or R1’s authorized person, and staff do not know if R1 and/or R1’s authorized person received a credit/refund for the dates in question. Additionally staff were not able to provide R1's financial records for January 2023. Financial records that were provided for May and June of 2023 revealed that R1’s authorized person received a refund, however the refund was not pertaining to the personal care credit/refund in question. Based on interviews, and file review, the above 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: 06/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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: 06/25/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/26/2024 Section Cited CCR 87625(b)(3)	1 2 3 4 5 6 7	87625(b)(3) Managed Incontinence (b) ...the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The ED shall submit a written memo of understanding of 87625 and also a plan indicating how the care staff will ensure that all incontinent residents are receiving proper and timely care in accordance with the regulation. Submit by 06/26/2024.
	8 9 10 11 12 13 14	Based on interviews, and file review the licensee did not comply with the section cited above when Staff did not respond timely and ensure R1 was kept dry, which posed an immediate health and safety/personal rights risk to residents in care.	8 9 10 11 12 13 14	ED will aslo ensure care staff receives training on the plan and submit in-service sign in sheets.
Type B 06/05/2024 Section Cited CCR 87507(f)	1 2 3 4 5 6 7	87507(f) Admission Agreements: The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The ED agreed to write a self-certification letter that they will follow up with coorperate, and Milestone management company in regards to R1's credit/refund, and issue a refund if needed. Will also wite a plan on how they will ensure refunds/credits are handled appropiately.
	8 9 10 11 12 13 14	Based on interview and record review, the licensee did not comply with the above cited section by not ensuring R1 and/or R1's authorized person recieved credit/refund for days R1 was not in the community which posed a potential health, safety, and personal rights risk for residents in care.	8 9 10 11 12 13 14	Submit POC by 07/05/2024.

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: 06/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2024

LIC9099 (FAS) - (06/04)

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