565802462-10-22-2024-29-AS-KLOZ-DAHSPT-20241029140341

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802462
Report Date: 10/22/2024
Date Signed: 10/22/2024 05:30:59 PM

Unsubstantiated

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
10/03/2024 and conducted by Evaluator Esther Cortez

COMPLAINT CONTROL NUMBER: 29-AS-20241003142431

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: 99	DATE:	10/22/2024
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Christian Castillo		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Facility does not provide a clean and safe environment for residents.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Esther Cortez conducted a subsequent complaint visit for the above allegation. Upon arrival, the LPA met with the Executive Director (ED) Christian Castillo, and was explained the reason for the visit. Entrance interview conducted.

On 10/07/24, between 10:30 a.m. and 2:00 p.m., the LPA toured the facility, interviewed the Executive Director, three (3) staff, six (6) residents, and obtained copies of resident records and other pertinent documents relevant to the investigation. During today's inspection, between 1:15 p.m. and 5:00 p.m., the LPA conducted a file review and interviewed five (5) residents, one (1) staff and obtained copies of pertinent documents relevant to the investigation.

Report will continue on LIC9099-C (2nd page).

Unsubstantiated

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: 10/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2024

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-20241003142431

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: 10/22/2024

NARRATIVE

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On the allegation "Facility does not provide a clean and safe environment for residents"; it is the concern of the reporting party that the facility environment is causing Resident #1 (R1) to cough and wheeze. The RP further reported that they believe R1’s room may have mold. To investigate the allegation the LPA conducted observations, file review and interviews. On 10/07/24, the LPA toured the facility and observed R1’s room. The LPA did not observe any evidence of the allegation while at the facility. The LPA did not observe any mold in R1’s room or any other room they visited. The LPA observed the facility clean and sanitary. Interviews with staff, residents and witness revealed that they have not observed mold at the facility and that housekeeping gets done once a week. Six (6) out of seven (7) residents interviewed revealed that they have no issues with coughing or wheezing. Interview with R1 revealed they went to the doctor to get lab testing done for mold exposure. R1’s lab results did not reveal any mold exposure. Staff and file review revealed that a work order had been submitted for mold in R1’s room, and that R1 could not breath. Maintenance staff went to inspect R1’s room and did not find mold in R1’s room. Staff also revealed that they had also previously worked on the air vents in R1’s room after a work order had been submitted regarding dust coming out through the air vent. On the allegation “Facility does not provide a clean and safe environment for residents,” Information obtained from interviews and file review revealed that staff and residents have not seen any mold at the facility, housekeeping gets done once a week, when a resident voices an issue or submits a work order, staff assists the residents and R1’s lab work did not reveal any mold exposure. Although the allegation may be valid, at this time, there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation is deemed Unsubstantiated at this time.

Exit interview conducted. Today's report was reviewed and emailed to the Executive Director.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2024

LIC9099 (FAS) - (06/04)

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