<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565802462
Report Date: 05/27/2021
Date Signed: 05/27/2021 03:15:02 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
05/24/2021 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20210524094151
FACILITY NAME:SAGE MOUNTAIN SENIOR LIVINGFACILITY NUMBER:
565802462
ADMINISTRATOR:MARTHA BERARDFACILITY TYPE:
740
ADDRESS:3499 GRANDE VISTA DRTELEPHONE:
(805) 375-0695
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91320
CAPACITY:145CENSUS: 67DATE:
05/27/2021
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Martha Berard - Executive Director TIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Room is malodorous.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analysts (LPAs) Brian Balisi and Martha Guzman-Chavez initiated a complaint investigation for the above allegations. LPAs met with Martha Berard and explained the reason for the visit.
Between 9:30am - 3pm, LPAs conducted a physical plant with Berard, interviewed staff, residents and reviewed and obtained copies of documents relevant to the investigation.
In regards to the allegation that Room is malodorous, during the investigation LPAs observed Resident 1 (R1s) bedroom to have a strong odor of pet urine. LPAs did not observe any other strong odors in the rest of the facility during the investigation. Based on information gathered during this visit, the department has sufficient evidence to determine that R1's room is malodorous. Therefore, the above allegation is SUBSTANTIATED at this time.

The following deficiencies were observed (See LIC 9099-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.




Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 29-AS-20210524094151
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SAGE MOUNTAIN SENIOR LIVING
FACILITY NUMBER: 565802462
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/11/2021
Section Cited
CCR
87303(a)
1
2
3
4
5
6
7
87303(a) Maintenance and operation:The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Administrator agreed to clean and sanatize R1's bedroom by June 11, 2021. LPAs will conduct a return vist to confirm if ordor was eliminated in R1s bedroom.
8
9
10
11
12
13
14
Based on LPAs observation, the facility failed to keep R1's bedrrom clean, safe and sanitary which poses a potential safety risk to residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3