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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603413
Report Date: 10/16/2024
Date Signed: 10/16/2024 12:20:11 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., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/14/2024 and conducted by Evaluator Abeye Duguma
COMPLAINT CONTROL NUMBER: 31-AS-20241014125547
FACILITY NAME:SAGE GLENDALE SENIOR LIVINGFACILITY NUMBER:
198603413
ADMINISTRATOR:SMITH,ANGELAFACILITY TYPE:
740
ADDRESS:525 W ELK AVETELEPHONE:
(818) 245-6378
CITY:GLENDALESTATE: CAZIP CODE:
91204
CAPACITY:113CENSUS: DATE:
10/16/2024
UNANNOUNCEDTIME BEGAN:
09:42 AM
MET WITH:Becky LangdonTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Facility staff are mismanaging resident's medication
Facility staff are not cleaning resident's room
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to this facility to investigate the above allegations. LPA met with Becky Langdon and explained the reason for the visit.

--- Facility staff are mismanaging resident's medication

It was alleged that the facility has been mismanaging her Resident #1’s (R1) medications. To investigate the allegation, on 10/16/2024 LPA requested pertinent documents at around 10:00a.m. and interviewed four (04) staff from 11:00 AM to 12:00 PM. A review of the Medication Administration Records, Current Medication Request, Notice to Pharmacy and Transmission Requests revealed that resident was not given their medications as prescribed.

(CONT. on LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
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 31-AS-20241014125547
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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: SAGE GLENDALE SENIOR LIVING
FACILITY NUMBER: 198603413
VISIT DATE: 10/16/2024
NARRATIVE
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During interviews with staff, Staff #1 (S1) and Staff #2 (S2) stated there was a delay in the notice to pharmacy process and that resident had a recent change in pain medications from “as needed” to scheduled that was also not given as prescribed.

Based on record review and interviews, there is enough information to verify the allegation. Therefore, the allegation is SUBSTANTIATED at this time.

--- Facility staff are not cleaning resident's room

It was alleged that facility staff have not been cleaning R1’s room. To investigate the allegation, on 10/16/2024 LPA conducted a physical plant tour at around 10:15a.m. and interviewed four (04) staff from 11:00 AM to 12:00 PM. During the physical plant tour, LPA observed that all rooms were clean and well maintained. During interviews with staff, Staff #4 (S4) stated that Staff #3 (S3) that was assigned to the room did not communicate to S4 that, due to personal reasons and scheduling, they were no longer able to clean R1’s room and that there was some miscommunication which resulted in the resident’s room not being cleaned for a period of two weeks.

Based on interviews, there is enough information to verify the allegation. Therefore, the allegation is SUBSTANTIATED at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):

No other health and safety hazards noted during the visit.

Exit interview conducted. Copy of this report issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20241014125547
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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SAGE GLENDALE SENIOR LIVING
FACILITY NUMBER: 198603413
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/18/2024
Section Cited
CCR
87465(a)(5)
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Incidental Medical and Dental Care (a)(5) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:
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Administrator will submit a written letter by the POC due date stating that they will review Title 22 Division 6 Chapter 8 of the CA Code of Regulations 87465 Incidental Medical and Dental Care and that going forward will adhere to these regulations.
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Based on record review and interviews, the licensee did not comply with the section cited by not assisting R1 with self-administered medications as prescribed which poses a potential health and safety and personal right risk to residents in care.
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Type B
10/18/2024
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidenced by:
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POC: Administrator will submit a written letter by the POC due date stating that they will review Title 22 Division 6 Chapter 8 of the CA Code of Regulations 87303 Maintenance and Operation and that going forward will adhere to these regulations.
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Based on interviews, the licensee did not comply with the section cited above as R1’s room was not cleaned for an extended time.
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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.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3