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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565802462
Report Date: 12/27/2024
Date Signed: 12/27/2024 11:53:57 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
10/30/2023 and conducted by Evaluator Erica Mosley
COMPLAINT CONTROL NUMBER: 29-AS-20231030120440
FACILITY NAME:SAGE MOUNTAIN SENIOR LIVINGFACILITY NUMBER:
565802462
ADMINISTRATOR:JANELLE LOPEZFACILITY TYPE:
740
ADDRESS:3499 GRANDE VISTA DRTELEPHONE:
(805) 375-0695
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91320
CAPACITY:145CENSUS: 93DATE:
12/27/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Executive Director, Christian Castillo TIME COMPLETED:
11:55 AM
ALLEGATION(S):
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Staff did not ensure residents medication was dispensed in a timely manner
Licensee does not ensure facility has sufficient amount of staff to meet the care needs of residents
INVESTIGATION FINDINGS:
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At 10:30 a.m.. Licensing Program Analyst (LPA) Erica Mosley conducted an unannounced subsequent complaint visit at the facility to deliver findings for the allegation listed above. The LPA met with Executive Director Christian Castillo and explained the reason for the visit.

On 11/07/2023, LPA Elsie Campos conducted observations of staff and residents pertaining to the complaint allegations, attempted resident interviews at 1:40 p.m. and 1:50 p.m., conducted interview with Executive Director at 3:10 p.m. and collected and reviewed pertinent records. On 11/25/2024, LPA Esther Cortez starting at 11:00 a.m., conducted a file review and four (4) staff interviews. The LPA has determined further investigation is needed.

Report continued on LIC9099-C....
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2024
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 6
Control Number 29-AS-20231030120440
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: SAGE MOUNTAIN SENIOR LIVING
FACILITY NUMBER: 565802462
VISIT DATE: 12/27/2024
NARRATIVE
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Report continued from LIC9099...

On 11/26/2024, LPA Cortez starting at 1:00 p.m. conducted four (4) resident and two (2) staff interviews. On 12/02/2024, between 11:40 a.m. and 4:30 p.m. LPA Cortez conducted two (2) staff and five (5) resident interviews. On 12/13/2024, LPA Cortez, between 01:00 p.m. and 4:15 p.m. interviewed two (2) staff, conducted a file review, and obtained copies of resident records and other pertinent documents relevant to the investigation. On 12/16/2024, between 10:30 a.m. and 4:30 p.m., LPA Cortez conducted five (5) staff interviews and obtained copies of pertinent documents relevant to the investigation.

On the allegations, “Staff did not ensure residents medication was dispensed in a timely manner, and Licensee does not ensure facility has sufficient amount of staff to meet the care needs of residents”; it is the concern of the reporting party that approximately around or on 10/10/2023, staff took three (3) hours to dispense morning medication to Resident 1 (R1) and Resident 2 (R2) and that the facility does not have enough care staff to provide care for all of the residents needs in a timely manner. To investigate the allegations, the LPA conducted interviews and file review.

Staff interviews revealed that MedTechs (MTs) are trained to document the time that a resident’s medicine is prepared and document after the medicine has been administered. The MT will log on to their online system and check what residents they will be assisting with medications. They will select the resident that they will be dispensing medications, after the medication has been prepared and is ready to be given, they will press the “PREP MED” button, and give the medication to the resident. After the medication is given, the MT will go back to their online system and press the “PASS MED” button to chart that the medication has been given. Staff revealed that there is certain times that after a medication has been given a MT may be called or stopped to assist with other things and may not chart right after the medication was passed. A review of R1’s Electronic Medication Administration Record (eMAR) revealed that on 10/12/2023, two of R1’s medications that were scheduled for 7:00 a.m. and one medication that was scheduled for 8:00 a.m. were documented as prepped at 11:27 a.m. and charted at 12:12 p.m. A file review revealed that R2 is no longer at the facility, and the LPA could not view R2’s eMAR. Furthermore, staff revealed that they have heard residents complained that they do not receive their medication on time and have heard other staff over the walkie talkie report that certain resident is still waiting for meds and has been an hour.

Report continued on LIC9099-C....

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20231030120440
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: SAGE MOUNTAIN SENIOR LIVING
FACILITY NUMBER: 565802462
VISIT DATE: 12/27/2024
NARRATIVE
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Report continued from LIC9099...
Interviews conducted with care staff and MedTechs revealed that a full staffed morning shift is four (4) caregivers and (2) MedTechs (MT) in Assisted Living and three (3) caregivers and one (1) MT in Memory Care. Six (6) out of eight (8) staff that were working at the community during 2023, recall or have knowledge of the community being understaffed, including in October of 2023 during the time the complaint was submitted. A staff revealed that there has been plenty of times that there have only been two (2) staff on the floor, they further revealed that there was one shift where they were the only staff in all four (4) floors in Assisted Living. The staff also revealed that it was noticeable that there were times that R1 had peed on themselves because staff did not get to them on time due to there not being enough staff. Other staff revealed that residents brought up concerns of staff being understaffed in the town hall meetings many times. Many staff revealed that the community is currently doing a lot better this year and believe their workload is manageable, however their workload can become not manageable if staff calls out and management does not have anyone to cover their shift. Additionally, staff revealed that their workload was not manageable in 2023. Staff revealed they often had to take on other’s responsibilities due to lack of staff and felt stressed and rushed. Furthermore, staff revealed that they felt bad for the residents during that time, because they were not getting the good service that they deserve. Two residents revealed that in 2023, the community was understaffed, and it was noticeable as staff would be in a hurry to assist, there were times they had to wait as much as two (2) hours for assistance.

Based on the information gathered through interviews and file review, although staff interviews revealed that staffing has improved, at the time the complaint was submitted the community did not have adequate staffing to assist resident with care needs. File review revealed that medications for R1 that were scheduled for 7:00 a.m. and 8:00 a.m. were documented as prepped until 11:27 a.m. and charted until 12:12 p.m. making them over three (3) hours late. Therefore, the allegations, “Staff did not ensure residents medication was dispensed in a timely manner, and Licensee does not ensure facility has sufficient amount of staff to meet the care needs of residents” are deemed Substantiated at this time.

Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 809-D).



Exit interview conducted, appeal rights discussed, and a copy of this report issued.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
10/30/2023 and conducted by Evaluator Erica Mosley
COMPLAINT CONTROL NUMBER: 29-AS-20231030120440

FACILITY NAME:SAGE MOUNTAIN SENIOR LIVINGFACILITY NUMBER:
565802462
ADMINISTRATOR:JANELLE LOPEZFACILITY TYPE:
740
ADDRESS:3499 GRANDE VISTA DRTELEPHONE:
(805) 375-0695
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91320
CAPACITY:145CENSUS: 93DATE:
12/27/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Executive Director, Christian Castillo TIME COMPLETED:
11:55 AM
ALLEGATION(S):
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Staff has inappropriate conversations with other facility staff in front of residents.
INVESTIGATION FINDINGS:
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At 10:30 a.m.. Licensing Program Analyst (LPA) Erica Mosley conducted an unannounced subsequent complaint visit at the facility to deliver findings for the allegation listed above. The LPA met with Executive Director Christian Castillo and explained the reason for the visit.

On 11/07/2023, LPA Elsie Campos conducted observations of staff and residents pertaining to the complaint allegations, attempted resident interviews at 1:40 p.m. and 1:50 p.m., conducted interview with Executive Director at 3:10 p.m. and collected and reviewed pertinent records. On 11/25/2024, LPA Esther Cortez starting at 11:00 a.m., conducted a file review and four (4) staff interviews. The LPA has determined further investigation is needed.

Report continued on LIC9099-C....
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20231030120440
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: SAGE MOUNTAIN SENIOR LIVING
FACILITY NUMBER: 565802462
VISIT DATE: 12/27/2024
NARRATIVE
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Report continued from LIC9099...

On 11/26/2024, LPA Cortez starting at 1:00 p.m. conducted four (4) resident and two (2) staff interviews. On 12/02/2024, between 11:40 a.m. and 4:30 p.m. LPA Cortez conducted two (2) staff and five (5) resident interviews. On 12/13/2024, LPA Cortez, between 01:00 p.m. and 4:15 p.m. interviewed two (2) staff, conducted a file review, and obtained copies of resident records and other pertinent documents relevant to the investigation. On 12/16/2024, between 10:30 a.m. and 4:30 p.m., LPA Cortez conducted five (5) staff interviews and obtained copies of pertinent documents relevant to the investigation.

On the allegation, “Staff has inappropriate conversations with other facility staff in front of residents,” it is the concern of the reporting party that Staff 1 (S1) yells and uses foul language at the care staff while in presence of the residents and visitors. The RP further revealed that they personally have never witness S1 yell or use foul language in front of the residences. Staff and File review revealed that S1 no longer works at the community. All staff interviewed regarding the allegation revealed that they have never witness or heard any staff speak inappropriately or yell in front of the residents. All residents interviewed revealed that they have not heard staff speak inappropriately in front of them. Based on interviews, there is insufficient evidence to support the above-mentioned allegation. The allegation, “Staff has inappropriate conversations with other facility staff in front of residents,” is unsubstantiated at this time.

Exit interview conducted. A copy of today's report was provided.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20231030120440
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SAGE MOUNTAIN SENIOR LIVING
FACILITY NUMBER: 565802462
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/10/2025
Section Cited
CCR
87465(a)(4)
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Incidental Medical and Dental Care. The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: This requirement was not met by evidence of eMAR indicating medication not provided
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POC- Administrator agrees all MTs will receive Medication training that includes documentation, and medication distribution. Submit proof of training to CCLD by POC due date.
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in a timely manner. Which poses an immediate risk to Residents in care.
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Type B
12/31/2024
Section Cited
CCR
87411(a)
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Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet residents’ needs. This requirement is not met as evidenced by:Based on file review and interviews, the licensee did not comply with the section cited above as
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The ED agrees to submit a written plan that will be implemented when staff call out to ensure that there is always staff coverage at all times by 12/31/2024.
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staff revealed that in 2023 the community was understaffed and were rushed to assist residents and residents had to wait long period of times to get assisted. This posed a potential health and safety risk for 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.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6