565802462-6-21-2021-29-AS-DPEA-CESUR8-20220526154818

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802462
Report Date: 06/21/2021
Date Signed: 06/21/2021 03:32:28 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 LIVING		FACILITY NUMBER:	565802462
ADMINISTRATOR:	MARTHA BERARD		FACILITY TYPE:	740
ADDRESS:	3499 GRANDE VISTA DR		TELEPHONE:	(805) 375-0695
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91320
CAPACITY:	145	CENSUS: 68	DATE:	06/21/2021
		UNANNOUNCED	TIME BEGAN:	12:27 PM
MET WITH:	Martha Berard - Administrator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Resident room not cleaned.

Room is in disrepair.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Brian Balisi and Martha Guzman-Chavez initiated a subsequent complaint investigation for the above allegations. LPAs met with Martha Berard and explained the reason for the visit.

Between 12:30pm - 2pm, LPAs conducted a physical plant with Berard, and obtained copies of pertinent documents relevant to the investigation.

In regards to the allegation that Room not cleaned, during the course of investigation LPAs received documentation that revealed Resident 1 (R1s) bedroom to have multiple stains on the carpet from dog extraments. Inteview with staff and witnesees also revealed that stains on the carpet were from R1s dog extraments as well. On 5/27/2021 LPAs observed (7) resident bedrooms to be clean and well kept. Based on information gathered during this visit, the department has sufficient evidence to determine that Resdient room was not cleaned. Therefore, the above allegation is SUBSTANTIATED at this time.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021

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-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
	VISIT DATE: 06/21/2021

NARRATIVE

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Continued from 9099

In regards to the allegation that Room is in disrepair, during the course of the investigation, LPAs observed an indentation in the wall in the kitchen above an electrical socket and a missing bracket on the toilet paper holder. On 5/27/2021 LPAs observed (7) resident bedrooms to be in good repair. Based on information gathered during this and previous visit, the department has sufficient evidence to determine that R1's room is in disrepair. 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.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021

LIC9099 (FAS) - (06/04)

Page: 2 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: 06/21/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/21/2021 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	POC was cleared during the visit Administrator stated carpet was replaced on 6/11/2021, and repairs to wall and toilet paper holder were observed to be repaired at this time.
	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 Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021

LIC9099 (FAS) - (06/04)

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