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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565802462
Report Date: 07/26/2022
Date Signed: 07/26/2022 06:26:14 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
07/18/2022 and conducted by Evaluator Kasandra Lopez
COMPLAINT CONTROL NUMBER: 29-AS-20220718165553
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: 96DATE:
07/26/2022
UNANNOUNCEDTIME BEGAN:
11:39 AM
MET WITH:Nicolle Hozner, Director of Health and WellnessTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Food served is not of good quality
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced initial 10 day complaint inspection at the facility today. The LPA arrived at 11:39 AM and met with the concierge. At 11:58 AM, the LPA met with Nicolle Hozner, Director of Health and Wellness as the Administrator Jill Ford was not available.

The allegation of 'Food served is not of good quality' alleges the food the facility serves make the resident sick and the resident was served spoiled cole slaw and a spoiled sandwich. During today's inspection between 11:58 AM and 4:00 PM, the LPA conducted interviews with Ms. Hozner, met with Culinary Director Michael Tabada, toured the kitchen, observed the food storage areas, interviewed Mr. Tabada, interviewed six staff, and interviewed two residents.

Report continued on LIC 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022
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 4
Control Number 29-AS-20220718165553
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: 07/26/2022
NARRATIVE
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During the inspection of the kitchen and food storage areas, the LPA observed food to be stored at the appropriate temperature. During the inspection, the LPA observed the following. Beginning at 12:54 PM in the refrigerator, the LPA observed Glenview Farms low fat cottage cheese with a best by date of 07/16/2022, Glenview Farms low fat cottage cheese with a best by date of 07/23/2022, and three Abbottford Farms single serve hard boiled egg packages with a use by date of 06/13/2022. In the dry storage area beginning at 1:07 PM, the LPA observed 2 boxes of Cream of Rice with best by dates of 10/17/2021, approximately six boxes of Cream of Rice with best buy dates of 03/30/2022, and approximately 10 boxes of Near East Couscous mix with best by dates of 07/11/2022. At 1:36 PM, the LPA observed the refrigerator again, and observed the only three packages of pre-washed green cabbage coleslaw mix with use by dates of 07/24/2022, and two packages of cauliflower with a use by date of 07/14/2022 and 07/23/2022. The LPA also observed two containers of opened Kraft coleslaw dressing and three or four unopened containers. None of the dressings had expiration dates on the packaging but Mr. Tabada was able to tell one of the open containers was older than the other due to different numbers on the packaging. Mr. Tabada looked though shipping receipts but was only able to find the invoice for the newer cole slaw dressing ordered on 06/30/2022 during the LPA's inspection. The LPA obtained photos of the food observed. The food in question, including the cole slaw dressing was disposed of during the inspection.

Based on the LPA's observation, there is sufficient evidence to support the allegation of Food served is not of good quality. Therefore, the allegation is deemed Substantiated at this time. The following deficiency was cited (See LIC 9099-D) from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Exit interview and report reviewed with the Director of Health and Wellness. A copy of the report and appeal rights were emailed.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
07/18/2022 and conducted by Evaluator Kasandra Lopez
COMPLAINT CONTROL NUMBER: 29-AS-20220718165553

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: DATE:
07/26/2022
UNANNOUNCEDTIME BEGAN:
11:39 AM
MET WITH:Nicolle Hozer, Director of Health and WellnessTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Facility does not have an operating dishwasher
Facility is unable to sanitize dishes
INVESTIGATION FINDINGS:
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During today's inspection regarding the above allegations, between 11:58 AM and 4:00 PM, the LPA conducted interviews with Ms. Hozner, met with Culinary Director Micheal Tabada, toured the kitchen, observed the food storage areas, interviewed Mr. Tabada, interviewed six staff, and interviewed two residents.

The allegations allege the dishwasher has been broken for 3-4 weeks and they are unable to sanitze the dishes. During the inspection, the LPA observed the dishwasher to be operational and heating to 170 degrees. Interviews revealed there have been issues with the dishwasher, but it has always been functioning and sanitzing the dishes, and repairs were done timely. Interviews also revealed the dishwasher was leaking on approximately July 3rd but it was still able to function until it was repaired. Maintenance records revealed service was last provided on 07/08/2022 and 04/26/2022. Based on this information, there is insufficient evidence to support the allegations of 'Facility does not have an operating dishwasher', and 'Facility is unable to sanitize dishes'. Therefore, the allegation is deemed unsubstantiated at this time. Exit interview and report reviewe with Ms. Hozner. A copy of the report and appeal rights were emailed.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 29-AS-20220718165553
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: 07/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/05/2022
Section Cited
CCR
87555(b)(8)
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87555 General Food Service Requirements (b)(8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.
This following requirement was not met as evidenced by:
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The Administrator shall submit a plan with procedures on how they will protect the safety, acceptability and nutritive values of food served. The plan shall be submitted by 08/05/2022.
(Items in question were disposed of during the inspection.)
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Based on observation, the licensee failed to comply with the section cited above as the LPA observed 8 food items with use by dates of 6/13/22, 7/14/22, 7/23/22 and 7/24/22, and multiple items with best by dates of 10/17/21, 3/30/22, 7/11/22, 7/14/22 and 7/23/22, which poses an immediate health 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: 07/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4