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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802462
Report Date: 02/01/2024
Date Signed: 02/01/2024 12:04:09 PM


Document Has Been Signed on 02/01/2024 12:04 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



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: 100DATE:
02/01/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Betsy Mccoy-Nursing DirectorTIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management Deficiencies inspection at the facility regarding deficiencies observed during the investigation of complaint control # 29-AS-20230125125751. The LPA met with Nursing Director Betsy Mccoy and explained the reason for the inspection.

During the investigation of complaint control # 29-AS-20230125125751, it was alleged that staff did not respond to a pendent call for assistance timely pertaining to a choking incident regarding Resident #1 (R1). During the course of the investigation, although there was insufficient evidence to support staff did not respond to a pendent call timely, there was sufficient evidence to support staff did not respond to a stat assistance for help with a choking incident timely as interviews revealed it took approximately seven (7) to eight (8) minutes for the S2 to respond and S2 utilized the elevator from the third floor to the first floor instead of using the stairs which is typically faster. Interviews conducted with witnesses also reflected that S2 did not perform the Heimlich maneuver or provide any type of life-saving procedures/medical interventions on R1 in the dining room.

More information pertaining to this investigation is under the LIC 9099 dated 02/01/2024 under complaint control # 29-AS-20230125125751.

During the course of the investigation, it also revealed S2’s first aid certification expired in February 2022, and S2 did not have a current certificate during the incident on 01/24/2023.
Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D).

Exit interview conducted, civil penalties issued, 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: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2024
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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Document Has Been Signed on 02/01/2024 12:04 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
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: 02/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
02/02/2024
Section Cited
CCR
87468.2(a)(2)

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87468.2 (a) In addition to the rights listed in Section 87468.1,....(4)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 as evidenced by:
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Licensee will submit a plan how you will ensure appropriate resident care and supervision, including medical intervention during an emergency. Submit to CCL by 2/2/2024.
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Based on interviews and records review, the licensee did not comply with the section cited above as staff failed to respond timely to an emergent situation pertaining to R1 which posed an immediate health and safety concern to R1 in care.
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Request Denied
Type B
02/09/2024
Section Cited
CCR87411(c)(1)

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87411 Personnel Requirements (c)All RCFE staff who assist residents... (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.This requirement is not met as evidenced by
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Licensee will submit a plan how you will ensure all staff have current first aid training. Submit to CCL by 1/09.2024
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Based on record review, the licensee failed to comply with the section cited above as S2’s first aid certification expired in February 2022, and S2 did not have a current certificate during the incident on 01/24/2023 which posed a 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: 02/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2024
LIC809 (FAS) - (06/04)
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