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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603413
Report Date: 07/18/2025
Date Signed: 07/18/2025 05:06:53 PM

Document Has Been Signed on 07/18/2025 05:06 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:SAGE GLENDALE SENIOR LIVINGFACILITY NUMBER:
198603413
ADMINISTRATOR/
DIRECTOR:		SMITH,ANGELAFACILITY TYPE:
740
ADDRESS:525 W ELK AVETELEPHONE:
(818) 245-6378
CITY:GLENDALESTATE: CAZIP CODE:
91204
CAPACITY: 113CENSUS: 78DATE:
07/18/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:10 AM
MET WITH:Memory Care Director (MCD), Syrina CanezTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Antonia Alvizar-Ettima met with the Memory Care Director (MCD) and made an initial complaint # 31-AS-20250714121426 visit to this facility. This Case Management has nothing to do with complaint visit.

During Complaint Investigation, LPA Alvizar-Ettima discovered the following Staff (S1) and (S2) have been present without a Criminal Background Clearance and Association to this facility. S1 stated their first day of work was 07/14/2025. S2 stated that their first day of work was 07/08/2025. LPA request/received staff S1 Nebraska and S2 California Driver’s License.

LPA Alvizar-Ettima verified using Guardian Background System Check, staff S1 and S2 names did not appeared on facility roster.

S1- Michelle L. Connot DOB: 10/31/1973

S2- Dawn Irene Monahan DOB: 08/11/1967

S1 indicated that she is an Entrim Executive Director of sister community in Nebraska. At about 11:30a.m., S1 left the facility to Burbank Airport and to take a flight to Nabraska. S1 indicated that she will not be returning back to this facility.

During today’s visit S2 was Criminal Background Clearance and Associated to this facility.

A citation and civil penalty were issued. Copy of this report was provided to Memory Care Director (MCD), Syrina Canez

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Antonia Alvizar-Ettima
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 07/18/2025 05:06 PM - It Cannot Be Edited


Created By: Antonia Alvizar-Ettima On 07/18/2025 at 04:15 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 07/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/21/2025
Section Cited
CCR
87355(b)(2)

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All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working... in a licensed facility: (2)Request a transfer of a criminal record clearance as specified in Section 87355(c)... This requirement is not met as evidence by:
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Memory Care Director (MCD) has agreed that S1 will not returning to facility until criminal background clearance and associate During today's visit S2 was criminal background clearance & associate. MCD provided a copy of proof clearing this citation.
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Based on interview and review of Guardian Background System Check facility Staff S1 and S2 are not criminal background clearanced and association to this facility. No documentation has been submitted to Community Care Licensing. This poses a potential 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.
Naira Margaryan
NAME OF LICENSING PROGRAM MANAGER:
Antonia Alvizar-Ettima
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2025


LIC809 (FAS) - (06/04)
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