565802462-9-23-2024-29-AS-ECOZ-D9E2HG-20240923172443

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565802462
Report Date: 09/23/2024
Date Signed: 09/23/2024 05:25:08 PM

Document Has Been Signed on 09/23/2024 05:25 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 LIVING		FACILITY NUMBER:	565802462
ADMINISTRATOR:	BETSY MCCOY		FACILITY TYPE:	740
ADDRESS:	3499 GRANDE VISTA DR		TELEPHONE:	(805) 375-0695
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91320
CAPACITY:	145	CENSUS: 94	DATE:	09/23/2024
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	Christian Castillo-ED		TIME COMPLETED:	05:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Esther Cortez conducted a subsequent case management visit to deliver findings for the above allegation. LPA met with Executive Director Christian Castillo and explained the reason for the visit. On 07/11/2023, the Department received a Report of Suspected Dependent Adult/Elder Abuse (SOC 341) from the facility regarding Resident #1 (R1). The report listed a possible sexual assault of an elderly resident diagnosed with mild cognitive impairment (MCI). The case was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Juan Lozano. On 07/12/2023, from 1:49pm to 4:10pm, Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Case Management Incident visit at the facility. LPA Lopez met with interim Administrator Julius Osorio and explained the reason for the visit. On 07/11/2023, the Department received a Report of Suspected Dependent Adult/Elder Abuse (SOC 341) completed 07/07/2023 from interim Administrator Julius Osorio. The SOC 341 report pertained to (R1) and Staff #1 (S1) for an alleged incident that occurred on 07/06/2023. On 07/11/2023, the LPA spoke with Mr. Osorio on the telephone regarding the alleged incident and he stated S1 was currently on leave pending an investigation. During the inspection, the LPA reviewed facility records and obtained pertinent copies. When the LPA arrived at the facility, there was a Ventura County Sheriff's vehicle outside the building. The LPA was advised that law enforcement was speaking with R1 at the time. A copy of the report number RB# 23-88897 was obtained. The LPA determined further investigation was needed and informed Mr. Osorio that the Community Care Licensing Division (CCLD) Investigation Branch (IB) Investigator Juan Lozano was assigned to the investigation. REPORT WILL CONTINUE ON LIC809-C.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

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
	VISIT DATE: 09/23/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

On 07/21/2023, from 11:05am to 11:30am, Investigator Lozano conducted interviews with R1 and R2; and on 07/24/2023, at 3:00pm, with S1. In addition, facility file documents related to R1 were reviewed. Law enforcement interviewed R1 and S1 and did not conduct any further investigation.

Information obtained from the investigation revealed that on 07/07/2023, R1 reported that on 07/06/2023 at approximately 1:30pm, when R1 had their meal tray delivered by S1, R1 stated that R1 needed assistance moving up in bed. Per R1, S1 offered to help and placed S1’s arms around R1 to lift R1 and then kissed R1 on the mouth. Per R1, after the incident, R1 asked S1 to leave the room. R1 stated Resident #2 (R2) was also in the room but reportedly did not see anything. R1 and R2 reside in the same room. The facility suspended S1 pending their investigation.

The facility took a statement from S1 on 07/08/2023 who denied the allegation. Per S1, the meal tray was delivered to R1 and R2. S1 setup their food on their tables. R1 asked for help sitting up in the bed, and S1 told R1 they were not able to assist but would get someone. S1 then stated that R1 asked if they could help change R1’s shirt to which S1 responded that they could not but would get someone to help with that also. S1 left to go get R1 tea they requested and came back to the room and finished setting up their food as they requested and left the room. S1 stated it was a total of approximately 6 minutes they assisted which included getting tea. S1 confirmed the R2 was present and sitting up.

Information obtained from the Department’s interviews with R1, R2, and S1 revealed all parties denied the allegation. Based on the conflicting statements made by R1 and R2, the Department determined it is unlikely that R1 was sexually assaulted at the facility. R1 denied being kissed by S1. R2 stated that R2 lives in the same room with R1 and denied seeing anyone kissing R1. S1 denied the allegation. The Department does not have sufficient evidence to support the above allegation. Therefore, the allegation “Resident was sexually assaulted at the facility” is deemed Unsubstantiated at this time.

Exit interview, copy of report given.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024

LIC809 (FAS) - (06/04)

Page: 2 of 2