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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802462
Report Date: 06/10/2022
Date Signed: 06/10/2022 06:25:43 PM


Document Has Been Signed on 06/10/2022 06:25 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:SAGE MOUNTAIN SENIOR LIVINGFACILITY NUMBER:
565802462
ADMINISTRATOR:JILL FORDFACILITY TYPE:
740
ADDRESS:3499 GRANDE VISTA DRTELEPHONE:
(805) 375-0695
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91320
CAPACITY:145CENSUS: 93DATE:
06/10/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Jill FordTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Case Management - Incident inspection at the facility today to follow up on self reported reports received. The LPA met with Administrator Jill Ford at 10:31am and explained the reason for today's inspection.

The LPA met with the Administrator and Nicole Hozner, Director of Health and Wellness, in the Administrator's office. On 05/28/2022, Community Care Licensing Division (CCLD) received a faxed death report pertaining to Resident#1 (R1) who passed away on 05/28/2022. The LPA reviewed facility records and discussed R1's history with the Administrator and Ms. Hozner between 11:10 AM and approximately 2:00 PM. The LPA obtained copies of pertinent records and determined further investigation is needed.

At 2:03 PM, the LPA began record review for Resident #2 (R2). On 05/22/2022, the LPA received an email at 8:38pm notifying the LPA of a memory care resident elopement on 05/22/2022. The Administrator reported the resident was found unharmed by law enforcement and a written report with more details would follow. On 05/27/2022, CCLD received a faxed incident report pertaining to R2 who eloped from the facility on 05/22/2022 at approximately 12:30 AM. The report states due to a new agency caregiver, Staff #1 (S1), misunderstanding instructions given by a facility caregiver, S1 assumed it was acceptable to allow R2 leave the secured memory care unit. At approximately 12:15am, S1 inputted the door code and allowed R2 to exit the memory care unit and observed R2 get on the elevator. At approximately 12:30am, the main lobby entrance door triggered the alert system notifying staff a resident had exited the community. An internal and external facility search was conducted by staff. At approximately 12:45am, Staff #2 (S2) called 911 to report a missing resident. At approximately 12:50am, police contacted S2 to report R2 had been found at a nearby McDonald's on Wendy drive. A separate police report was made by a bystander which made R2's return back to the facility quicker. Police returned R2 back to the facility at approximately 1:00am. S2 assessed R2 upon there return and did not observe any injuries. Report continued on LIC 809-C.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2022
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 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/10/2022
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At 12:50am, R2's POA was contacted via telephone. The report states they informed the care giving agency that S1 should no longer be assigned to work at the facility and to ensure agency staff have thorough dementia training when assigned in memory care.

Record review revealed a Missing Resident Checklist, and Resident Elopement Assessment was conducted on 05/22/2022 for R2. Records also revealed R2 has a diagnosis of dementia and is not allowed to leave the facility unassisted. A map search reflects the McDonald's were R2 was found is 0.8 miles away from the facility and takes approximately 23 minutes to walk to.

At approximately 3:30pm, the LPA me with Ms. Hozner who stated she spoke with S1 on 05/22/2022 after the incident and they stated they misunderstood and thought the resident could walk around freely in assisted living. Based on the information obtained, there is sufficient evidence to issue a deficiency as staff allowed R2 out of a secured unit when they are not able to leave the facility unassisted.

During today's visit when the LPA arrived, there was a "post it note" on the facility door bell indicating the bell did not work and to knock on the door for assistance The facility's entry door has been locked from the outside since the pandemic, therefore concierge opens the front door for guests. The Administrator stated the door bell stopped working recently and a part had been ordered. The LPA inquired about the protocol for late night guests, deliveries, medical personnel, etc. when the concierge is gone for the day. The Administrator stated there was a phone number posted on the door for after hours guests that calls directly to the medication room. The LPA and Administrator checked the facility door and did not observe any phone number posted. The Administrator stated the number was previously posted and immediately posted the phone number on the door during the inspection. The Maintenance Director stated the door bell would still alert the staff's Ipod's when pushed although, Ms. Hozner along with the LPA, pushed the door bell and it did not alert the Ipod Ms. Hozner had with her. Based on this information, a deficiency will be issued.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Exit interview and report reviewed with the Administrator. A copy of the report and appeal rights will be emailed.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 06/10/2022 06:25 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/10/2022
Section Cited

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87411 Personnel Requirements - General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
This requirement is not met as evidenced by:
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Based on record review and interview, the licensee failed to comply with the section cited above as S1 allowed R2 to leave the secured memory care unit unassisted resulting in S2 eloping from the facility which is an immediate health and safety risk to residents in care.
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Type B
06/10/2022
Section Cited

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87303 Maintenance and Operation
(a) 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 is not met as evidenced by:
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Based on observation and interview, the licensee failed to comply with the section cited above as a phone number was not posted on the locked entry door for after hour guests, emergencies, deliveries, etc. to alert staff of their presence which poses a potential health, safety, and personal rights risk to residents in care.
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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: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2022
LIC809 (FAS) - (06/04)
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