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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802462
Report Date: 03/22/2022
Date Signed: 03/23/2022 03:20:02 PM

Document Has Been Signed on 03/23/2022 03:20 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: 92DATE:
03/22/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Jill FordTIME COMPLETED:
05:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Case Management - Incident inspection at the facility today. The LPA met with Administrator Jill Ford at 3:10 PM.

During the course of the investigation of complaint control #29-AS-20220322104533, the LPA observed two staff, Staff #1 (S1) and Staff #2 (S2) were not associated to the facility. S1's date of hire is 02/03/2022 and S2's date of hire is 03/16/2022.. This deficiency warrants an immediate civil penalty. This is also a repeat violation of the same citation that was issued on 11/22/2021.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Civil penalties assessed. Failure to correct the deficiencies may result in civil penalties. Exit interview and report reviewed with Jennifer Miller, Business Office Manager. A copy of the report and appeal rights was emailed.

On 03/23/2022, the LPA amended the 03/22/2022 report as civil penalties were assessed incorrectly for Staff #2 (S2) as S2 only worked at the facility for two days. The amended Civil Penalty Assessment - Caregiver Background Check LIC 421BG now reflects civil penalties in the amount of $100 a day for 30 days for S1 and $100 a day for 2 days for S2.



The amended report was reviewed with Administrator Jill Ford over the telephone at 2:59 PM. A copy of the report and appeal rights were emailed to the Administrator for signature.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2022
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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Document is an Amendment of Original Document on 03/23/2022 02:38 PM


Created By: Kasandra Lopez On 03/22/2022 at 04:45 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
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: 03/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/22/2022
Section Cited
CCR
87355(e)(2)

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87355 Criminal Record Clearance(e) All individuals subject to a criminal record review pursuant to... 1569.17(b) shall prior to working, residing or volunteering 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 evidenced by:

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This is a repeat violation of a citation issued on 11/22/2021. Subsequent violations within a twelve (12) month period will result in a civil penalty of one hundred ($100) per violation per day for a maximum of thirty (30) days.
Civil penalties of $100 a day will continue to accrue until proof S1 & S2 are associated or proof they no longer work at the facility.
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Based on record review and interview, the licensee failed to comply with the section cited above as two staff (S1 &S2) are not associated to the facility which poses an immediate health and safety concern 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 Perera
LICENSING EVALUATOR NAME:Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2022


LIC809 (FAS) - (06/04)
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