Inspection Reports for
Sagebrook Senior Living

The visit was complaint-related due to an incident where resident R1 eloped from the facility on February 19, 2026. The complaint was substantiated with a Type B citation issued.

The facility failed to ensure the safety of resident R1 who left the facility unassisted before the concierge started their shift, posing a potential health and safety risk. A Type B citation was issued, and corrective actions including 1:1 caregiver assignment and earlier concierge start time were implemented and cleared during the visit.

The facility was previously cited for a violation related to a client eloping due to staff not starting their shift. The deficiency has been cleared as confirmed during this visit.

The facility was generally well maintained with proper safety measures, medication labeling, and documentation. However, two Type B deficiencies were cited: lack of documentation proving one staff member per shift had active CPR and First Aid training, and resident and personnel files were inaccessible for two hours during the inspection.

The facility responded appropriately to the incident by implementing in-service training, updating signage, and holding care conferences. The resident was safely returned with no injuries and has since relocated. A technical violation was issued during the visit.

The complaint investigation was substantiated for the allegation that a resident sustained multiple injuries due to neglect and lack of supervision. The allegation that a resident was not properly assessed and placed upon admission was unsubstantiated. Staff failed to provide proper care and supervision leading to injury. A civil penalty was assessed.

The complaint that a resident sustained multiple injuries due to neglect and lack of supervision was substantiated, with findings that staff failed to provide appropriate care and supervision resulting in injury. The allegation that a resident was not properly assessed and placed upon admission was found to be unsubstantiated due to lack of corroborating evidence. A civil penalty of $250 was assessed for repeated violations within a 12-month period.

The resident was safely located and returned with no injuries. The facility implemented in-service training, updated signage, and held care conferences. A technical violation was issued during the visit.

The complaint investigation was substantiated for neglect/lack of supervision leading to multiple injuries to resident R1. The allegation regarding improper assessment and placement upon admission was unsubstantiated.

The complaint that a resident sustained multiple injuries due to neglect and lack of supervision was substantiated, with evidence showing staff failed to provide appropriate care and supervision resulting in injury. The allegation that a resident was not properly assessed and placed upon admission was unsubstantiated due to conflicting information and lack of corroborating evidence.

The facility was found to be clean, well-maintained, and compliant with most regulations, including proper food storage, medication management, and staff certifications. One technical violation was issued for oxygen use signage not posted in a resident's shared bedroom, and a tool bag with potentially dangerous items was secured and addressed with the resident's family.

The facility was found to be clean, well-maintained, and compliant with most regulations. However, a technical violation was issued for failure to post appropriate oxygen use signage in a resident bedroom, and a tool bag containing potentially dangerous items was found and secured.

The facility was found to have an incident where a resident left without supervision, posing a potential health and safety risk. The facility responded by updating the resident's care plan, increasing supervision, and implementing front door security measures. The cited deficiency was cleared at the time of the visit.

The facility responded appropriately by updating the resident's level of care, increasing monitoring, securing the front door during evening hours, and implementing overnight front desk attendance. The deficiency cited was cleared at the time of the visit.

The facility was generally compliant with physical plant and safety requirements; however, deficiencies were found related to failure to obtain and transfer criminal record clearances for two individuals (S1 and S2), posing immediate health and safety risks. Civil penalties were assessed for these violations.

The facility was generally compliant with physical plant and safety requirements; however, deficiencies were found related to criminal record clearance for staff members S1 and S2, posing immediate health and safety risks. Civil penalties were assessed for these violations.

The complaint was substantiated based on interviews, observations, and record reviews. The allegation was that staff did not repair the resident's bathroom window which was difficult to open and close, posing a risk of injury.

The investigation found that the bathroom window in the resident's room was indeed very tight and difficult to operate, confirming the allegation. The maintenance director attempted to loosen the window with WD-40 oil but was unsuccessful. The deficiency was substantiated and cited under California Code of Regulations, Title 22.

The complaint alleged that staff did not repair the resident's bathroom window. The allegation was substantiated based on the investigation.

The investigation found that the bathroom window in resident R1's room was very hard to open and close, posing a potential health risk. The allegation was substantiated after interviews, observations, and attempts to operate the window.

The complaint was substantiated based on interviews, observations, and record reviews. Allegations included failure to repair resident's window, leaking radiator heater, and hazardous placement of a space heater next to resident's bed.

The investigation substantiated that the resident's window had been broken since 2021 and was not repaired timely, the radiator heater in the resident's room was leaking, and a space heater was placed too close to the resident's bed posing a safety hazard.

The complaint investigation was substantiated based on evidence that the resident's window was broken since 2021 and not repaired timely, the radiator heater was leaking, and a hazardous space heater was placed next to the resident's bed. The preponderance of evidence standard was met.

The investigation substantiated three allegations: the facility did not repair a resident's broken window which had been in disrepair since 2021, the radiator heater in the resident's room was leaking, and a hazardous space heater was placed too close to the resident's bed posing a safety risk.

The complaint investigation was based on allegations including staff not responding to resident calls, facility disrepair, failure to safeguard resident belongings, unsafe accommodations, and lack of respect for resident privacy. The allegation regarding safeguarding resident belongings was substantiated, while others were unsubstantiated or unfounded.

The investigation found most allegations to be unsubstantiated or unfounded, including staff responsiveness, facility repair, safe accommodations, and respect for resident privacy. However, the allegation that the facility did not safeguard a resident's personal belongings was substantiated due to staff washing a dry clean only duvet in a regular washer, damaging it.

The visit was complaint-related following a report that a caregiver engaged in inappropriate contact with a resident. The staff member denied sexual contact but acknowledged an emotional relationship. The resident was unable to consent. The complaint was substantiated based on preponderance of evidence.

The investigation found preponderance of evidence that a staff member engaged in inimical behavior and inappropriate contact with a resident, violating the resident's personal rights. The staff member was removed from the facility.

The complaint investigation was triggered by allegations including staff not responding to resident calls, facility disrepair, failure to safeguard resident belongings, unsafe accommodations, and staff disrespecting resident privacy. The allegation regarding safeguarding resident belongings was substantiated, while others were unsubstantiated or unfounded.

The investigation found most allegations to be unsubstantiated or unfounded, including staff responsiveness, facility repair, safety accommodations, and respect for resident privacy. However, the allegation that the facility did not safeguard a resident's personal belongings was substantiated due to staff washing a dry clean only duvet in a regular washer, damaging it.

The investigation found preponderance of evidence that staff member S1 engaged in inimical behavior and inappropriate contact with a resident, violating the resident's personal rights. S1 was removed from the facility immediately.

The complaint was substantiated based on interviews and records review, confirming that the resident did not receive regular showers and did not have safe healthful accommodations as required.

The investigation substantiated that the facility did not provide regular showers to the resident, instead providing sporadic showers and sponge baths, failing to ensure basic services and safe, healthful accommodations, posing an immediate health, safety, or personal rights risk.

The complaint was substantiated. The allegation that a resident did not receive showers due to lack of staff was found valid based on evidence including staff interviews and documentation.

The investigation found that the resident had not received showers since June 2020 and was given sponge baths instead due to a staff shortage. The allegation was substantiated based on the preponderance of evidence.

Investigation of complaint 14-AS-20201029181101 found that the resident's condition changed to require three person assist and the facility failed to obtain authorization to retain the resident with prohibited health conditions.

The facility retained a resident with prohibited health conditions without requesting an exception or obtaining authorization, and no provisions were made to transfer the resident to a higher level of care. The care plan was changed from regular showers to sponge baths due to the resident's increased care needs.

The facility was found to be inconsistent in submitting required daily COVID-19 linelists to Community Care Licensing on 11/10, 11/11, and 11/12. Additionally, a COVID-19 positive staff case on 11/6 was not reported within the required 24-hour timeframe, and the facility failed to submit requested staff rosters on 11/11 and 11/12.