Pricing ranges from
    $7,426 – 9,653/month
    1. Home
    2. Assisted Living
    3. California
    4. Thousand Oaks

    Sage Mountain

    3499 Grande Vista Dr, Thousand Oaks, CA, 91320
    4.1 · 76 reviews
    • Assisted living
    • Memory care
    For pricing and availability(510) 508-4507
    For the front desk(805) 375-0695

    Pricing

    $7,426+/moSemi-privateAssisted Living
    $8,911+/mo1 BedroomAssisted Living
    $9,653+/moStudioAssisted Living

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    Amenities

    Healthcare services

    • Activities of daily living assistance
    • Assistance with bathing
    • Assistance with dressing
    • Assistance with transfers
    • Medication management
    • Mental wellness program

    Healthcare staffing

    • 12-16 hour nursing
    • 24-hour call system
    • 24-hour supervision

    Meals and dining

    • Diabetes diet
    • Meal preparation and service
    • Restaurant-style dining
    • Special dietary restrictions

    Room

    • Air-conditioning
    • Cable
    • Fully furnished
    • Housekeeping and linen services
    • Kitchenettes
    • Private bathrooms
    • Telephone
    • Wifi

    Memory care community services

    • Mild cognitive impairment
    • Specialized memory care programming

    Transportation

    • Community operated transportation
    • Transportation arrangement
    • Transportation arrangement (non-medical)

    Common areas

    • Beauty salon
    • Computer center
    • Dining room
    • Fitness room
    • Gaming room
    • Garden
    • Outdoor space
    • Small library
    • Wellness center

    Community services

    • Concierge services
    • Fitness programs
    • Move-in coordination

    Activities

    • Community-sponsored activities
    • Planned day trips
    • Resident-run activities
    • Scheduled daily activities

    4.08 · 76 reviews

    Overall rating

    1. 5
    2. 4
    3. 3
    4. 2
    5. 1

    • Care

      3.8

    • Staff

      4.0

    • Meals

      4.4

    • Amenities

      4.2

    • Value

      2.5

    Location

    Map showing location of Sage Mountain

    About Sage Mountain

    Sage Mountain is a large, newer senior living community located along a hillside in Thousand Oaks, California, managed by Agemark Senior Living. The facility offers assisted living, memory care, and short-term respite care, which means people can stay for a short time if they need extra help or if their caregivers need a break. Sage Mountain has a special memory care program called In the Moment®, which gives residents with Alzheimer's disease or other kinds of dementia a safe place to live and person-centered support focused on their needs. The staff is trained and available 24 hours a day to help with things like medication, dressing, bathing, and transferring. Rooms and common spaces are large with big windows to let in lots of sunlight, and people can take in beautiful sunrise and sunset views of the Conejo Valley and the nearby mountains from walking paths, patios, and the secure courtyard. People say the setting is warm, inviting, and feels like a hotel, with resort-style amenities such as all day restaurant-style dining, an in-house theater, a resident fitness center, a yoga studio, and a salon for haircuts and styles. There are regular musical programs and many group activities that help everyone connect and enjoy each other's company. Staff help with cooking, cleaning, laundry, and other chores, and there are programs that focus on wellness, social connections, and healthy aging. Residents have choices for how they want to live, eat, and spend their time, and the facility is committed to keeping everyone as safe and comfortable as possible. While Sage Mountain is not part of the Elderwerks network, it offers specialized support for a range of care needs, and the atmosphere aims to help residents feel cared for and even lucky to be there.

    People often ask...

    State of California Inspection Reports

    97

    Inspections

    34

    Type A Citations

    23

    Type B Citations

    6

    Years of reports

    13 Aug 2025
    Investigated two self-reported incidents in which a resident was reportedly inebriated, fell twice, and was transported to a hospital by emergency services. Found that after the first fall a 1:1 was assigned, with the 1:1 remaining in the room during the second fall, and hourly safety checks were in place.
    • § 9058
    13 Aug 2025
    Identified a self-reported incident of missed doses of a prescribed medication on two dates caused by a staff error when updating the order and discontinuing the old one without approval. Executive Director stated the resident is doing fine with no symptoms.
    • §
    • § 9058
    19 May 2025
    Found two self-reported unusual incidents involving residents: on 04/10/2025, one resident was noted sitting on the floor with hip pain and was transported to hospital, later found to have a fractured pelvis; on 04/26/2025, another resident was lying on the floor with bleeding around the left ear and transported, later evaluated with two small subdermal brain bleeds. Interviews with staff were conducted; no immediate health and safety concerns were observed.
    • § 9058
    19 May 2025
    Investigated the allegation that staff did not prevent a resident from harming other residents. Interviews, observations, and record reviews showed staff were present and intervened promptly, and there was no conclusive evidence confirming or refuting that the incident occurred as described.
    24 Mar 2025
    Identified that staff did not report changes in condition to the resident's authorized representative, did not seek medical attention promptly, mismanaged medications, did not meet the resident's needs, and the resident fell multiple times. This resulted in a civil penalty of $9,500 for serious bodily injury.
    • § 9058
    14 Mar 2025
    Investigated a self-reported incident where a resident reportedly took pills and was transported to the hospital after staff were alerted, with the resident on med management, away from the community on 02/18/25 and back on 02/27/25, and not disclosing an outside prescription filed on 02/19/25. Interviewed the administrator and one staff member, reviewed records, began a medication audit, and planned a follow-up visit.
    09 Jan 2025
    Investigated a self-reported death of a resident; power outage noted, interviews and a file review conducted; no deficiencies cited.
    09 Jan 2025
    Investigated a self-reported death of a resident found unresponsive in the memory care unit's common area; noted a power outage during the visit and referred the case to the investigations branch for further review.
    27 Dec 2024
    Found that morning medications for residents were prepared late and staffing levels were insufficient to meet residents’ care needs at the time. Found no evidence that staff spoke inappropriately or yelled in front of residents.
    • § 87411(a)
    • § 87465(a)(4)
    27 Dec 2024
    Identified staffing shortages in 2023 that led to delays in helping residents with care needs. Found no conclusive evidence that those delays caused urinary tract infections, as records showed residents were assisted and there was no medical documentation linking UTIs to care delays.
    26 Nov 2024
    Identified that staff does not respond to resident's call button in a timely manner. Records showed a resident waited about 35 minutes to be assisted on 9/11/2023, with several calls waiting more than 15 minutes and some up to 43 minutes, and average reset times around 38 minutes.
    • § 87468.2(a)(4)
    21 Nov 2024
    Investigated the allegation that a resident was overcharged and did not receive an itemized bill. Found that the community shifted to a tiered care-level pricing system with notices and temporary concessions, and that available records and interviews did not provide clear evidence of overcharging or missing itemization at this time.
    18 Nov 2024
    Identified several health and safety deficiencies during an unannounced visit, including dirty carpets in multiple resident rooms, sticky restrooms and floors, and improper storage of medications and cleaning products. Noted functioning fire safety equipment and adequate food supplies, while record review was incomplete due to time constraints, with plans to return for a follow-up.
    • § 87303(a)
    • § 87705(f)(2)
    • § 87309(a)
    22 Oct 2024
    Investigated the allegation that meals were not of good quality. Found that fresh vegetables were stocked, a menu-based meal plan was used, and residents reported satisfaction with the food.
    22 Oct 2024
    Investigated the allegation that the environment was not clean and safe and that mold might be present; found no evidence of mold and observed a clean, sanitary setting. Interviews and records showed most residents had no coughing or wheezing, the resident in question had medical tests showing no mold exposure, and a mold-related work order was reviewed with maintenance inspecting vents without finding mold.
    07 Oct 2024
    Found cleaning supplies left unattended in a hallway accessible to residents; staff later locked them away after being reminded cleaning products should not be left where residents could access them. A citation was issued.
    23 Sept 2024
    Found insufficient evidence to support the allegation that a resident was sexually assaulted at the site.
    23 Sept 2024
    Investigated a sexual assault allegation involving a resident and staff member, found conflicting statements and insufficient evidence to support the claim.
    25 Jun 2024
    Identified the allegation that staff did not respond timely to a resident's toileting needs, resulting in accidents. Identified the allegation that staff billed a resident for personal care during periods when the resident was absent from the community.
    25 Jun 2024
    Investigated theft of credit card information involving two residents, with police reports reportedly filed and a theft-and-loss program in place. The ED said that card details were stolen, not the physical cards, and that the investigation may require a follow-up visit.
    25 Jun 2024
    Investigated a theft incident where two residents reported their credit card information was stolen outside the facility, and the staff confirmed an ongoing investigation and police reports related to the matter.
    18 Jun 2024
    Found evidence supporting the allegations that neglect and lack of supervision led to a resident sustaining a fracture, and that staff did not respond to a call for assistance in a timely manner or seek medical care. Found insufficient evidence to support the allegation that a stage III pressure injury existed due to neglect before hospice care, and insufficient evidence to support odor and soiled laundry concerns.
    • § 1569.312(a)
    • § 87465(j)
    • § 87468.2(a)(4)
    18 Jun 2024
    Identified that a resident fell on December 30, 2022; an unknown staff member informed the resident's representative that the resident was in some pain but okay, and the business manager described it as slipping from a chair, with no incident documentation completed. Hospital evaluation on January 5, 2023 found injuries linked to the fall, and a citation was issued.
    18 Jun 2024
    Investigated allegations of neglect related to Resident #1, including pressure injuries, failure to respond to call for assistance, and lack of medical care, with findings indicating that staff neglected to respond promptly and did not seek necessary medical attention, resulting in resident injuries.
    17 Jun 2024
    Identified that staff did not safeguard a resident's personal supplies. Found that a staff member admitted taking incontinent supplies and did not provide copies of requested records to the resident or their authorized person.
    • § 87506(c)(1)
    • § 87217(b)
    17 Jun 2024
    Investigated that staff took resident’s personal incontinence supplies without safeguarding them and failed to provide complete copies of requested resident records, including documentation of a recent fall.
    • § 87625(b)(3)
    • § 87507(f)
    07 May 2024
    Found no evidence of inadequate food service; residents reported good meals, timely room service, and a newly hired chef improving options. Found that staff generally met residents' needs and transportation was provided, but identified concerns about safeguarding belongings (missing laundry and discarded clothing) and observed pendant-call response delays, especially on weekends.
    07 May 2024
    Reviewed multiple allegations including inadequate food service, staff not meeting residents' needs, inadequate transportation, slow response to call pendants, and mishandling of residents' belongings; found evidence supporting some concerns, leading to citations being issued.
    01 Feb 2024
    Investigated allegation that Resident #1 choked to death due to neglect and lack of supervision, finding that staff did not provide timely life-saving intervention in the dining room. Identified delays in staff response to the emergency and noted that a staff member’s first aid certificate had expired.
    • § 87468.2(a)(4)
    01 Feb 2024
    Investigated allegations found staff did not respond promptly to a stat call during a choking incident, taking about seven to eight minutes, and used the elevator instead of stairs. Identified that the staff member’s first aid certification had expired prior to the incident, there was no current certification at the time, and interviews indicated no Heimlich maneuver or other life-saving measures were performed.
    • § 87411(c)(1)
    • § 87468.2(a)(2)
    01 Feb 2024
    Investigated the death of a resident who choked without timely medical intervention and found staff failed to respond promptly during the emergency, as well as lacking proper first aid certification.
    • § 87309(a)
    15 Nov 2023
    Found multiple health and safety deficiencies, including Bedroom 319 at 83°F, a strong odor in Bedroom 241, a sticky floor in Bedroom 237 restroom, a sink that wouldn’t drain in Bedroom 241 restroom, and no observed emergency food and water supply. Noted safety devices—smoke and carbon monoxide detectors and fire extinguishers—were present and recently serviced, and the team planned to return to finish the visit.
    15 Nov 2023
    Found that the facility maintained safe and sanitary conditions, with appropriate food storage, functioning safety systems, and adequate staffing and resident care, though issues with room temperature, odors, and restroom maintenance were noted. Some deficiencies were identified that require correction to ensure ongoing compliance.
    • § 87468.2(a)(4)
    • § 1569.153(c)(d)
    25 Sept 2023
    Found that a resident died on 9/17 after being found on the bathroom floor around 8:27 p.m. by staff during evening medications. Emergency responders arrived, the remains were released to the family, no hospital or coroner examination occurred, prior symptoms included a cough and heavy breathing on 9/16 with a negative COVID test and an attempted physician follow-up that did not occur, and no deficiencies were observed.
    25 Sept 2023
    Reviewed a resident’s sudden death after a fall in a memory care setting; no deficiencies were observed during the investigation.
    01 Aug 2023
    Found that staff initial training was incomplete and annual training not completed. Found insufficient evidence that unqualified staff cooked meals.
    • § 1569.625(b)(1)
    • § 87411(c)(1)
    • § 1569.69
    01 Aug 2023
    Investigated the allegations that staff cooked without proper certification and that staff training was incomplete and outdated; found that only qualified staff cooked resident meals and that staff training records were incomplete.
    • § 87211(a)(1)
    25 Jul 2023
    Investigated the allegation that a resident was sexually harassed while in care and found no evidence to support that anyone exposed themselves or acted inappropriately toward the resident. Interviews with residents, staff, and a family member did not reveal any incidents of sexual impropriety.
    25 Jul 2023
    Investigated the allegation that a resident was sexually harassed while in care; interviews and record reviews revealed no evidence of inappropriate or exposed behavior by anyone, leading to an unsubstantiated conclusion.
    • § 87303(a)(1)
    • § 1569.695(a)(2)
    • § 87303(e)(6)
    12 Jul 2023
    Determined the allegation of physical abuse involving a resident could not be supported by the evidence available. Interviews with the resident, family, and staff suggested the injury occurred during a fall while being assisted to a shower bench, with differing accounts regarding who witnessed the incident.
    12 Jul 2023
    Found that a resident requiring a two-person transfer had only one staff member assisting during a transfer, and the resident sustained a skin tear.
    12 Jul 2023
    Investigated an alleged case of abuse involving a resident and a staff member. On-site law enforcement spoke with the resident, and an investigator was assigned to the case.
    12 Jul 2023
    Investigated an allegation that a resident sustained a laceration during a shower fall; findings indicated insufficient evidence of abuse or neglect.
    07 Jul 2023
    Investigated the allegation that resident records are not accurate and the allegation that residents are not receiving appropriate care. Found insufficient evidence to support either claim.
    07 Jul 2023
    Investigated whether resident records were accurate and if residents received appropriate care; found insufficient evidence to support both allegations.
    30 Jun 2023
    Investigated the allegation that staff financially abused residents and found insufficient evidence to support it. Reviewed records and interviews about prior thefts and did not identify staff involvement.
    30 Jun 2023
    Reviewed records during a complaint investigation and identified a deficiency due to a medical assessment on file for a resident with dementia being over one year old.
    • § 87705(c)(5)
    30 Jun 2023
    Reviewed resident records and identified a missing or outdated medical assessment for a resident with dementia, which is required to be current according to licensing regulations.
    24 May 2023
    Found doorbells at the main entrance and outside memory care were labeled and functioning. Found pendent call wait times exceeded 20 minutes on several days and residents reported delays; no clear evidence supported after-hours access problems or medication deliveries being delayed.
    • § 87468.2
    24 May 2023
    Found insufficient evidence to support the allegation of insufficient staffing; the allegation was deemed unsubstantiated.
    24 May 2023
    Identified that a resident did not receive all morning medications on time and staff mismanaged medications; pendent-call responses were often delayed. Found insufficient evidence to support that the administrator spent a sufficient amount of time in the building.
    • § 87468.2(a)(4)
    • § 87465(a)(4)
    24 May 2023
    Found that the administrator did not spend enough time in the facility, medication delivery was delayed and improperly managed for residents, staff responded slowly to pendent calls, and staff falsely recorded medication administration; some allegations were supported by evidence, while others were not.
    12 Apr 2023
    Reviewed a death notification and related records for a resident; the cause of death was unknown and no deficiencies were cited at this time. Noted that the mortuary was contacted and that the death certificate would not be ready for about a week, to be forwarded when received.
    12 Apr 2023
    Investigated and found that staff did not respond to resident pendent calls in a timely manner. Found insufficient evidence to support the allegations that carpet stains in the resident's apartment were not addressed, that wheelchair maneuvering was not safe, that meals were inadequate in portion size, or that cleaning was not performed as scheduled.
    12 Apr 2023
    Reviewed a death report related to a resident who passed away shortly after hospitalization; the cause of death was unknown, and additional information was pending receipt of the death certificate.
    • § 87468.2(a)(4)
    16 Feb 2023
    Investigated the claim that a resident's personal rights were violated by blocking the ombudsman from attending council meetings. Found that interviews with residents showed the ombudsman could be invited when needed and no one was told not to invite them, so there was not enough evidence that the allegation occurred.
    16 Feb 2023
    Found insufficient evidence to support the allegation that residents fear speaking with the ombudsman. Interviewing six residents revealed no fear of speaking with the ombudsman or retaliation for doing so.
    16 Feb 2023
    Found no evidence to support the allegation that residents felt fearful to speak with the long-term care ombudsman or feared retaliation, as residents interviewed expressed no such concerns.
    10 Feb 2023
    Investigated a complaint that staff drank alcohol while on duty; social media posts and photos taken in the memory care area showed an alcoholic beverage and staff seen drinking. Found insufficient evidence that residents were left unattended during a potluck, with interviews and schedules indicating residents were supervised, and noted a deficiency.
    10 Feb 2023
    Investigated allegations that staff drank alcohol while on duty and left residents unattended during a birthday potluck; found sufficient evidence to support the staff drinking alcohol while working.
    18 Jan 2023
    Identified that a staff member's criminal record clearance was not transferred and linked to this location, even though the staff member had worked there since August 2022. Found this to be a repeat violation within twelve months, resulting in civil penalties of $100 per day for up to 30 days.
    18 Jan 2023
    Identified a recurring violation where staff members' criminal record clearances were not properly transferred to the facility, resulting in civil penalties; the issue was addressed during an unannounced inspection following a previous citation within the past year.
    • § 87468.1
    13 Dec 2022
    Investigated two allegations: services not being provided in a timely manner and residents being left soiled for an extended period. Interviews with residents and staff indicated care was generally responsive and incontinence needs were met, with some delays during a significant COVID outbreak and staffing shortages.
    13 Dec 2022
    Investigated six allegations at the home: inadequate staffing; safeguarding residents’ belongings; residents’ authorized representatives not notified of changes; residents not offered activities; appropriate variety of foods not provided; and staff did not ensure resident received meals. Found insufficient evidence to support a violation for each allegation, considering the COVID outbreak, cohorting, and efforts to maintain safety and care.
    13 Dec 2022
    Found that residents received timely services despite COVID-related challenges, and staff ensured incontinence needs were met; no evidence supported the allegations that services were delayed or residents were left soiled for extended periods.
    • § 87355
    26 Oct 2022
    Investigated five specific allegations about care: staff did not report a change in condition to the resident's authorized representative; did not seek medical attention promptly; mismanaged the resident's medications; did not ensure the resident's needs were met; and the resident fell multiple times while under care. Identified contributing issues, including significant weight loss, delayed communication with medical providers and family, and gaps in monitoring after falls.
    • § 87466
    • § 87465(a)(4)
    • § 87555(b)(5)
    • § 87463(b)
    • § 87464(f)(1)
    26 Oct 2022
    Investigated the allegation that the resident died due to lack of care and supervision; found insufficient evidence to support that claim.
    26 Oct 2022
    Investigated concerns that lack of care and supervision contributed to a resident’s death, with findings indicating insufficient evidence to establish a direct connection between the care provided and the resident’s passing.
    14 Oct 2022
    Identified multiple unwitnessed falls with injuries and hospital visits by a resident, and the home failed to report these falls to licensing.
    14 Oct 2022
    Found infection control measures were in place (central entry screening, adequate PPE, and proper cleaning protocols) with one deficiency noted—the audible alarm in memory care front desk/medication room area was not operational when tested.
    • § 87303
    14 Oct 2022
    Reviewed incidents of resident falls and determined the facility failed to report multiple falls to licensing authorities. Concluded there were no issues related to the resident’s death but identified a reporting deficiency.
    15 Sept 2022
    Investigated the allegation that staff did not assist a resident with showering. Found insufficient evidence to prove the violation; no deficiencies were cited.
    15 Sept 2022
    Investigated the allegation that a resident was physically abused while in care. Found that discoloration was noted in 2020, hospital evaluation indicated no injury, and the resident did not report pain; evidence insufficient to prove a violation occurred.
    15 Sept 2022
    Found the allegation that a resident developed a severe infection while in care unsubstantiated due to insufficient evidence.
    15 Sept 2022
    Investigated whether a resident was physically abused, finding that although there was an observed discoloration, there was no evidence or reports of injury or pain, leading to an inconclusive conclusion regarding abuse.
    • § 87211
    26 Jul 2022
    Found spoiled cole slaw and a spoiled sandwich, along with outdated stock in the refrigerator and dry storage areas, which were disposed of. Observed the dishwasher operating and sanitizing dishes.
    26 Jul 2022
    Found that the residents were served spoiled food, including spoiled cole slaw and a spoiled sandwich, which compromised food quality. Identified that the dishwasher was functioning and sanitizing dishes despite past issues, with expired food items also observed during the inspection.
    10 Jun 2022
    Identified that a dementia-diagnosed resident was allowed to leave a secured memory care unit unassisted after a new agency caregiver misunderstood instructions. Noted the main entrance door bell did not alert staff, after-hours contact information was not posted, and that the information was added during the visit.
    10 Jun 2022
    Reviewed incident reports indicating a resident with dementia left a secured unit without assistance, and identified issues with the door bell system and emergency contact posting, resulting in deficiencies noted during the inspection.
    30 Mar 2022
    Identified that one resident developed a Stage IV pressure injury while in care, and a $500 civil penalty was issued. Insufficient evidence to support that another resident's death resulted from lack of care, that a resident had active tuberculosis, or that there was a scabies outbreak.
    30 Mar 2022
    Investigated allegations that the resident developed a pressure injury due to lack of care and supervision, and found insufficient evidence to support the claim; also reviewed other concerns including resident death, potential TB exposure, and a possible scabies outbreak, with all related findings deemed unsubstantiated.
    22 Mar 2022
    Identified that two staff members were not associated with the site, resulting in civil penalties for both and noting a repeat violation from a prior citation.
    22 Mar 2022
    Identified that two staff members working without proper authorization, resulting in civil penalties due to repeated violations. Amended penalties reflected shorter employment durations for one staff member.
    02 Mar 2022
    Identified that three memory care residents eloped through a delayed egress patio door on 01/29/2022 and staff did not hear the alarm because they were busy with other residents. Found the alarm was very faint inside the dining area, and all caregiver alert devices were stored in a docking station with none on staff, meaning no audible alert when doors opened.
    02 Mar 2022
    Reviewed a resident elopement incident where staff did not hear the alarm due to its faint sound and staff not carrying alert devices, leading to a citation for inadequate alarm audibility in the memory care outdoor patio. Further investigation into a prior reported abuse incident was also noted.
    • § 1569.312(a)
    22 Nov 2021
    Identified deficiencies related to infection control and safety, including an unlocked laundry room with cleaning supplies and a staff member not associated with the site.
    22 Nov 2021
    Reviewed for compliance, including infection control practices, safety measures, and medication storage, with some deficiencies observed related to unlocked areas and staff association.
    • § 87355
    09 Sept 2021
    Found that LTCO representatives visited on 4/9/2021, were not escorted, and could move freely, with one entering a resident room and staying and another walking around without meeting privately with residents. Determined insufficient evidence to support the allegation that staff prevented confidential meetings between LTCO and residents.
    09 Sept 2021
    Determined that staff allowed LTCO representatives to move freely and visit residents without escort or confidentiality, and found insufficient evidence to support the allegation that staff prevented confidential meetings between LTCO and residents.
    • § 87468.1
    22 Jul 2021
    Found no evidence to support the allegation that laundry room trash isn’t emptied regularly, based on resident interviews and a prior inspection, with trash cans in the laundry rooms observed to have lids and contain only some trash.
    22 Jul 2021
    Investigated the allegation that laundry room and resident room trash were not being emptied regularly, and interviews and observations indicated no issues with trash management.
    • § 87468.2(a)(4)
    21 Jun 2021
    Identified that a resident's room was not cleaned and in disrepair, based on observations during a visit and staff interviews. Evidence included carpet stains from a dog and a wall indentation near an electrical outlet, supporting these concerns.
    • § 87303(a)
    21 Jun 2021
    Determined that a resident's room was not cleaned, with stains from dog excrement found on the carpet, and identified disrepair in another resident's room, including an wall indentation and missing toilet paper holder bracket.
    • § 87555(b)(8)
    27 May 2021
    Identified the allegation that a resident's room was malodorous. Observed a strong odor of pet urine in that room, with no other strong odors found elsewhere.
    • § 87303(a)
    27 May 2021
    Investigated a complaint about a room being malodorous and found the resident's room had a strong pet urine odor, confirming the allegation. Noted additional deficiencies related to regulations and safety standards.
    • § 87303
    • § 87411
    27 Dec 2019
    Found that staff updated care plans appropriately in response to residents' health changes, but identified that staffing shortages led to inadequate assistance with transfers for residents requiring two-person help.
    15 Nov 2019
    Investigation confirmed that insulin was administered to a resident by non-licensed staff, and found that a resident with an unstageable wound was retained without proper authorization or hospice status.
    • § 87705(f)(2)
    • § 87355(e)(2)
    • § 1569.695(a)(2)

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