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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802462
Report Date: 01/09/2025
Date Signed: 01/09/2025 04:25:56 PM

Document Has Been Signed on 01/09/2025 04:25 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/
DIRECTOR:		BETSY MCCOYFACILITY TYPE:
740
ADDRESS:3499 GRANDE VISTA DRTELEPHONE:
(805) 375-0695
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91320
CAPACITY: 145CENSUS: 90DATE:
01/09/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:55 AM
MET WITH:Christian CastilloTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management – Incident visit to the above facility. The LPA met with Executive Director Christian Castillo and explained the reason for the visit. Entrance interview conducted.

The reason for today's inspection is to follow up on a self-reported death report received on 11/05/2024, and The report pertains to the death of Resident #1 (R1). It was reported that on 11/02/2024, R1 was found unresponsive in the common area of the memory care unit..

During today's visit, the LPA conducted an interview with the ED, conducted a brief tour of the facility and obtained copies of pertinent documents. Community was experiencing a power outage, any necessary pertinent documents will be sent to the LPA.

This incident was referred to Community Care Licensing Investigations Branch (IB) for review. If, further investigation is warranted an investigator or the LPA will return at a later date.

Exit interview conducted. A copy of the report was issued to the ED.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2025
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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