197608878-2-16-2021-29-AS-JAPL-BYCSH6-20210218125302

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608878
Report Date: 02/16/2021
Date Signed: 02/16/2021 11:07:56 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
11/02/2020 and conducted by Evaluator Ashley Smith

COMPLAINT CONTROL NUMBER: 29-AS-20201102121122

FACILITY NAME:	MEADOWBROOK AT AGOURA HILLS		FACILITY NUMBER:	197608878
ADMINISTRATOR:	KAWANA ANTHONY		FACILITY TYPE:	740
ADDRESS:	5217 CHESEBRO RD		TELEPHONE:	(818) 991-3544
CITY:	AGOURA HILLS	STATE: CA	ZIP CODE:	91301
CAPACITY:	185	CENSUS: 80	DATE:	02/16/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Kawana Anthony		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Resident sustained a broken bone while in care
Facility failed to seek timely medical attention for resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ashley Smith conducted a subsequent complaint visit to deliver findings. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s investigation was conducted via Zoom with Executive Director Kawana Anthony.

On 11/02/2020, the Department received a complaint stating that on 9/16/2020, after being discovered as unconscious at the facility, Resident #1 (R1) was admitted to the hospital with a diagnosis of UTI which led to sepsis, was malnourished and severely dehydrated, and had an untreated broken arm. R1 passed away on 09/17/2020 at the hospital. Community Care Licensing Division’s Investigations Branch (IB) Investigator Laura Garcia was assigned to the case. On 11/3/2020, the LPA interviewed the Executive Director at 11:47am and conducted a virtual tour at 11:55am. Investigator Garcia reviewed medical records on 12/22/2020; interviewed a physician on 12/13/2020 at 11am; interviewed a family member on 12/10/2020 at 8:30am; interviewed staff on 1/5/2021 at 1pm; on 1/14/2021 at 11:30am, 12pm, and 1pm; on 1/26/2021 at 9:30am; and, interviewed a home health nurse on 1/25/2021 at 10am.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2021

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 8

Control Number 29-AS-20201102121122

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MEADOWBROOK AT AGOURA HILLS	FACILITY NUMBER: 197608878
	VISIT DATE: 02/16/2021

NARRATIVE

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Regarding the allegation: Resident sustained a broken bone while in care
It was alleged that R1 was admitted to the hospital on 9/16/2020 with a broken bone. A review of hospital records revealed that R1 was admitted with an acute fracture of the left proximal humerus. Interviews with staff revealed that staff claimed they were unaware that R1 suffered a fracture. However prior to R1 being hospitalized on 9/16/2020, interviews revealed that R1 suffered an un-witnessed fall within a week prior to the incident. A review of Home Health Notes revealed that on 9/14/2020, a staff disclosed to the home health nurse that R1 suffered a fall on 9/12/2020. Witnesses claimed they found R1 on the floor, and that the fall was reported to a medication technician, whom then checked R1 for pain or bruising and only identified small scratches on R1’s elbows. The LPA nor the IB Investigator were able to identify documentation pertaining to the 9/12/2020 fall. It is unknown as to whether R1 was observed by paramedics as a result of the fall, as there is no supporting documentation.

An interview with a home health nurse revealed that on 9/14/2020, R1 was observed with a swollen left hand and R1’s rings were tight on their fingers. Upon noticing R1’s hand, the home health nurse asked staff about R1’s hand, which was when staff disclosed R1’s recent fall. The home health nurse attempted to remove R1’s rings, but was unable to do so. Home health notified R1’s primary care physician of the need for R1's hand to be x-rayed. Results from the x-ray revealed no fractures of R1’s left hand. Home health notes reflect that the morning of 9/16/2020, the home health nurse was able to remove R1’s rings, and informed staff of proper aftercare of R1’s hand. Furthermore, interviews and documentation revealed that the morning of 9/16/2020, staff informed home health that R1 potentially suffered another fall prior to the home health nurse seeing R1 the morning of 9/16/2020. One caregiver noted that R1 was found unresponsive in their bed, and another medication technician reported that R1 was found unresponsive on R1’s couch, seemingly that morning. However, staff interviews were unable to confirm these occurrences. As such, there was no documentation reflecting R1’s hand, the x-ray and the subsequent findings, or the possible falls the morning of 9/16/2020.

At the time of the incident, R1’s assessment revealed that R1 ambulated with a walker and required extensive assistance with all activities, close supervision due to fall risks, required assistance with dressing and showering, and daily body assessments. In addition, it is the staff’s responsibility to have noted swelling, pain, discolorations, or any unusual changes as it pertains to the resident’s well-being. As such, staff were unable to provide additional details regarding R1’s injuries, whether R1 expressed pain, nor did they document any pertinent information. CONT 9099-C

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 8

Control Number 29-AS-20201102121122

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MEADOWBROOK AT AGOURA HILLS	FACILITY NUMBER: 197608878
	VISIT DATE: 02/16/2021

NARRATIVE

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Staff claimed that they were unaware of R1’s upper arm or additional injuries; however, one staff exclaimed that prior to the 9/16/2020 incident that they noticed that R1’s arm was bruised, purple, and swollen, but they did not have information as to how it was sustained. On 9/16/2020 at approximately 4pm, staff approached R1 for dinner and found R1 unresponsive with shallow breathing. Staff called 911, performed CPR on R1, and R1 was then hospitalized. It was upon hospital admittance that it was discovered that R1 sustained an acute fracture of the left proximal humerus.

Based on the investigation, there is sufficient evidence to support the claim that R1 sustained a broken bone while in care. Staff provided inconsistent statements regarding the condition of R1’s hand and arm, and the facility was unable to provide any communication logs, unusual incident reports or details of the resident’s falls, swollen hand, or arm condition. When R1’s hand was observed to be swollen, home health inquired about an x-ray being done, not facility staff. A review of the x-rays confirmed R1’s left forearm, left wrist, and left hand were x-rayed, and no fractures were identified. However, hospital medical records determined that the fracture was located on the humerus, which is the long bone in the arm that runs from the shoulder to the elbow. The mobile x-ray did not capture the humerus. However, whereas the x-ray did not capture the entire left arm, the need for x-rays was identified by home health, not facility staff, whom were responsible for conducting regular body assessments of R1. This allegation is deemed Substantiated at this time.

Regarding the allegation: Facility failed to seek timely medical attention for resident
It was alleged that upon admittance to the hospital on 9/16/2020, R1’s broken arm appeared to have been untreated for several days. Interviews revealed that staff were unaware that R1 suffered a broken bone; however, it was revealed that R1 suffered a fall prior to being hospitalized on 9/16/2020. Staff were unable to provide any documentation, incident reports or details of R1's previous falls or arm condition. Interviews also revealed that staff were aware of R1’s swollen left hand, but the statements provided by staff regarding the bruising, swelling and the responsibility for reporting the change in condition were inconsistent. In addition, R1’s arm was x-rayed because home health reached out to R1’s primary care physician, not the staff. There was no change of condition reflected for R1 in the Facility Progress Notes from 8/19/2020-9/16/2020. Yet, evidence obtained through interviews revealed that R1 suffered at least one fall on 9/12/2020 and had a swollen left hand which required x-rays. As the above-mentioned incidents were overlooked and not properly reported, based on the investigation, there is sufficient evidence to support the claim that the facility failed to seek timely medical attention for R1. This allegation is deemed Substantiated at this time.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 8

Control Number 29-AS-20201102121122

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MEADOWBROOK AT AGOURA HILLS	FACILITY NUMBER: 197608878
	VISIT DATE: 02/16/2021

NARRATIVE

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An immediate civil penalty of $500 was issued today and the licensee was informed that an additional civil penalty is still being determined and might be assessed based on Health and Safety Code §1569.49. An additional civil penalty of $250 is also assessed today for the facility repeating the same violation within a 12 month period.

The following deficiencies were observed (See LIC 9099-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 conducted. A copy of the report was provided via email for signature, along with appeal rights.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 8

Control Number 29-AS-20201102121122

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MEADOWBROOK AT AGOURA HILLS	FACILITY NUMBER: 197608878
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/16/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/18/2021 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	Basic Services. Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidence by:	1 2 3 4 5 6 7	The Administrator has agreed to do the following: 1. Schedule vendor-approved training regarding Regulation 87464. Training must be completed in the next three weeks. Submit scheduled date to CCLD by 2/18/2021.
	8 9 10 11 12 13 14	Based on the investigation, the licensee did not comply with the section cited above, as R1 suffered a broken bone unknown to staff, which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	2. Submit Statement of Understanding, detailing how the facility will maintain compliance of Regulation 87464. Submit by 2/18/2021. Facility was cited for this deficiency on 3/12/2020; Civil Penalty of $250 issued for repeat violation.
Type A 02/18/2021 Section Cited CCR 87466	1 2 3 4 5 6 7	Observation of the Resident. When changes such as … a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Administrator has agreed to do the following: 1. Schedule vendor-approved training regarding Regulation 87466. Training must be completed in the next three weeks. Submit scheduled date to CCLD by 2/18/2021.
	8 9 10 11 12 13 14	Based on the investigation, the licensee did not comply with the section cited above, as the facility did not properly report or document R1’s falls, swelling and bruising of the left hand, and R1 suffered a broken bone unknown to staff, which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	2. Submit Statement of Understanding, detailing how the facility will maintain compliance of Regulation 87466. Submit by 2/18/2021. Immediate Civil Penalty of $500 assessed due to a violation that resulted in injury.

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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2021

LIC9099 (FAS) - (06/04)

Page: 5 of 8

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
11/02/2020 and conducted by Evaluator Ashley Smith

COMPLAINT CONTROL NUMBER: 29-AS-20201102121122

FACILITY NAME:	MEADOWBROOK AT AGOURA HILLS		FACILITY NUMBER:	197608878
ADMINISTRATOR:	KAWANA ANTHONY		FACILITY TYPE:	740
ADDRESS:	5217 CHESEBRO RD		TELEPHONE:	(818) 991-3544
CITY:	AGOURA HILLS	STATE: CA	ZIP CODE:	91301
CAPACITY:	185	CENSUS: 80	DATE:	02/16/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Kawana Anthony		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Questionable Death
Due to neglect, resident was malnourished
Due to neglect, resident sustained a severe infection leading to sepsis
Due to neglect, resident was severely dehydrated

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 6 of 8

Control Number 29-AS-20201102121122

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MEADOWBROOK AT AGOURA HILLS	FACILITY NUMBER: 197608878
	VISIT DATE: 02/16/2021

NARRATIVE

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Regarding the allegation: Questionable Death
It was alleged that due to facility negligence, R1 passed away on 9/17/2020. Interviews conducted with R1's primary care physician revealed that due to R1’s age, medical condition and declining prognosis that it was difficult to determine what lead to R1’s death. A review of R1’s death certificate revealed that the immediate cause of death was determined to be cardiovascular failure. Interviews conducted with facility staff did not provide sufficient evidence to support the claim that the facility was negligent in providing for R1’s care needs and if those were the factors of the primary cause of death. A review of hospital documents and nursing notes did not display concern or evidence of facility negligence or abuse against R1. Based on the investigation, there is insufficient evidence to support the claim that due to facility negligence, R1 passed away. The allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Due to neglect, resident was severely dehydrated
It was alleged that due to facility negligence, R1 was severely dehydrated. Interviews conducted with R1's primary care physician revealed that due to R1’s age, medical condition and declining prognosis that it was difficult to determine if facility staff were negligent in ensuring that R1 was properly hydrated. Interviews conducted with facility staff did not provide sufficient evidence to support the claim that the facility was negligent in providing for R1’s care needs. A review of home health documentation and facility notes did not reveal that R1’s ability to consume fluids or foods were a concern. Home Health Notes documented that R1 was encouraged to hydrate on 9/4/2020, 9/9/2020, 9/11/2020, 9/14/2020 and 9/16/2020. A review of hospital documents and nursing notes did not display concern or evidence of facility negligence or abuse against R1. Based on the investigation, there is insufficient evidence to support the claim that due to facility negligence, R1 was severely dehydrated. The allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Due to neglect, resident was malnourished
It was alleged that due to facility negligence, R1 was malnourished. Interviews conducted with R1's primary care physician revealed that due to R1’s age, medical condition and declining prognosis, that it was difficult to determine whether R1 was malnourished as a result of facility negligence. Staff interviews did not provide sufficient evidence to support the claim that the facility was negligent in providing for R1’s care needs. A review of home health documentation and facility notes did not reveal that R1’s ability to consume fluids or foods were a concern. A review of home health documents revealed that R1 was on a low-salt, low-fat diet. However on the physician’s report, there was no reported special diet. CONT 9099-C

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2021

LIC9099 (FAS) - (06/04)

Page: 7 of 8

Control Number 29-AS-20201102121122

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MEADOWBROOK AT AGOURA HILLS	FACILITY NUMBER: 197608878
	VISIT DATE: 02/16/2021

NARRATIVE

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Home health notes displayed evidence that the home health nurse provided education to staff on the benefits of R1 complying to their diet. In addition, on 9/16/2020, the home health nurse noted witnessing R1 eating their meal. A review of hospital documents and nursing notes did not display concern or evidence of facility negligence or abuse against R1. Based on the investigation, there is insufficient evidence to support the claim that due to facility negligence, R1 was severely malnourished. The allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Due to neglect, resident sustained a severe infection leading to sepsis
It was alleged that due to facility negligence, R1 sustained a severe infection, which led to sepsis. Interviews with R1's primary care physician revealed that due to R1’s age, medical condition and declining prognosis, that it was difficult to determine whether R1 developed an infection as a result of facility negligence. Interviews with facility staff did not provide sufficient evidence to support the claim that the facility was negligent in providing for R1’s care needs. A review of facility and home health notes did not reveal that the resident verbalized any discomfort when urinating. Whereas it was evident that R1 sustained a Urinary Tract Infection (UTI) which ultimately led to sepsis, there is insufficient evidence to support the claim that the development of the infection was due to facility negligence, and not as a result of R1’s medical diagnosis or prognosis. The allegation is deemed Unsubstantiated at this time.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was emailed for signature.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2021

LIC9099 (FAS) - (06/04)

Page: 8 of 8