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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608878
Report Date: 05/22/2020
Date Signed: 05/22/2020 06:01:47 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE. SUITE 200
GOLETA, CA 93117
FACILITY NAME:MEADOWBROOK AT AGOURA HILLSFACILITY NUMBER:
197608878
ADMINISTRATOR:VANESSA JEWELLFACILITY TYPE:
740
ADDRESS:5217 CHESEBRO RDTELEPHONE:
(818) 991-3544
CITY:AGOURA HILLSSTATE: CAZIP CODE:
91301
CAPACITY:185CENSUS: 114DATE:
05/22/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:50 PM
MET WITH:Keith Bernabe, LVNTIME COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) Ashley Smith conducted a Case Management-Incident visit at 4:50pm. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s investigation was conducted telephonically with Keith Bernabe.

This facility submitted a special incident report (SIR) on 5/21/2020, reporting an allegation of inappropriate sexual touching. It was alleged that resident #1 (R1) touched resident #2 (R2) inappropriately in the elevator. R2 reported this to staff, to which staff interviewed both R1 and R2. R1 confirmed that it took place, yet stated that the touch was consensual. R2 was interviewed, yet did not recall the touch being consensual. The responsible parties of both residents were notified, a SOC341 was submitted, and LTCO was contacted.

During today's call, the LPA interviewed staff regarding the incident. Further investigation is needed before findings can be delivered.

Exit interview conducted. A copy of the report was emailed for signature.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2020
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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