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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565802462
Report Date: 09/15/2022
Date Signed: 09/16/2022 09:09:12 AM

Unsubstantiated


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
01/26/2021 and conducted by Evaluator Kelly Dulek
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20210126140443
FACILITY NAME:SAGE MOUNTAIN SENIOR LIVINGFACILITY NUMBER:
565802462
ADMINISTRATOR:JADE ALMA-HARRISFACILITY TYPE:
740
ADDRESS:3499 GRANDE VISTA DRTELEPHONE:
(805) 375-0695
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91320
CAPACITY:145CENSUS: 93DATE:
09/15/2022
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Jill Ford/Jennifer MillerTIME COMPLETED:
05:32 PM
ALLEGATION(S):
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Facility staff are not assisting resident with hygiene needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kelly Dulek initiated a subsequent complaint investigation for the allegation listed above. LPA arrived at 10:45AM and met with Executive Director Jill Ford. Entrance interview conducted.

During today’s visit, LPA interviewed Executive Director Jill Ford throughout the visit, reviewed pertinent records at 11:00AM, toured the facility with Health and Wellness Director at 02:15PM, and conducted interviews between 02:22PM and 03:55PM. Previously, during an initial complaint inspection on 02/05/2021, LPA Dulek conducted a telephone interview with the administrator at 9:07AM, a video tour at 11:56AM, and LPA requested copies of pertinent documents. The following was then determined:

It was alleged that facility staff are not assisting resident (Resident #1 – R1) with showering. Record
CONTINUED ON LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022
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-20210126140443
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: 09/15/2022
NARRATIVE
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Continued from LIC 9099

review revealed that R1 initially planned to move into the Memory Care unit and was not receiving any additional care services. However, when R1 moved in, they moved into an Assisted Living unit, rather than Memory Care. Care plan was completed on 07/03/2020 and indicated “staff to assist with a shower daily. Wash hard to reach areas and encourage (R1) to participate as much as (they) are able to.” Physician’s Report dated 06/19/2020 indicated R1 had a diagnosis of Dementia and R1’s capacity for self-care indicated R1 was unable to bathe self, unable to dress/groom self, and unable to care for own toileting needs and that R1 was receiving hospice care at the time. Review of additional care notes revealed that R1 was on hospice during the time of the complaint allegation, however it is unclear whether hospice care plan included showering the resident or if the responsibility for assisting the resident was solely that of the facility staff. Care notes revealed that R1 also had a private caregiver when R1 moved into the facility, and R1 refused assistance with dressing and refused to be checked by the private caregiver. It is unclear whether R1 always had a private caregiver assisting with R1’s care needs, or just at the time of admit into the facility. Interview revealed that staff assist residents at least twice per week up to daily with showers, based on their agreed upon care plan as determined by the resident and their family. Staff will stay with the resident and shower them to ensure they are clean, dry and changed following their shower. If a resident just needs a standby assist, staff will stay with the resident the entirety of their shower. Interview revealed that many families prefer the hospice agency to assist with showers, but hospice typically only visits up to 4 times a week, so if a resident on hospice required daily showers, some would be provided by the facility staff and some by hospice staff. If a resident refuses a shower for any reason, staff would note this in the care notes. Care notes for R1 did not indicate any shower refusal. Based on record review and interview, although the allegation may be valid, at this time there is insufficient evidence to prove a violation occurred, therefore the allegation that “facility staff are not assisting resident with hygiene needs” is deemed UNSUBSTANTIATED at this time.

No deficiencies were cited. Exit interview conducted with Jennifer Miller, Business Office Manager. A copy of the report was provided to the Administrator via email.

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022
LIC9099 (FAS) - (06/04)
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