197608878-12-5-2021-29-AS-JAPL-CCE3PY-20220310172618

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608878
Report Date: 12/05/2021
Date Signed: 12/05/2021 04:27:12 PM

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
03/08/2021 and conducted by Evaluator Ashley Smith

COMPLAINT CONTROL NUMBER: 29-AS-20210308144820

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:	ZIP CODE:	91301
CAPACITY:	185	CENSUS: 88	DATE:	12/05/2021
		UNANNOUNCED	TIME BEGAN:	11:50 AM
MET WITH:	Lauria Gallagher		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff are mishandling medication
Failure to report unusual incidents

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced for a subsequent complaint visit. The LPA met with Community Relations Director Lauria Gallagher and explained the reason for the visit.

During the initial virtual on 03/15/2021, the LPA interviewed staff at 1:23pm and requested pertinent documents. During the 10/04/2021 visit, the LPA conducted a tour at 9:30 a.m., interviewed staff at 10:15 a.m., 10:37 a.m., 11:45 a.m., 11:57 a.m. and 3:30 p.m., interviewed residents at 11:50 a.m., and 11:55 a.m., and reviewed records at 3:00 p.m.

During today’s visit, the LPA interviewed staff at 12:30 p.m., 12:50 p.m., 1:02 p.m., 1:30 p.m., and interviewed six residents from 1:40 p.m. – 2:10 p.m.

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: 12/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2021

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

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20210308144820

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: 12/05/2021

NARRATIVE

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Regarding the allegation: Staff are mishandling medication
It was alleged that medication errors were happening, primarily on weekends. During today’s visit, interviews revealed that on 11/28/2021, there was a medication error in the Memory Care Unit, where approximately twenty-eight (28) residents did not receive their 5:00 p.m. dosage of medication due to an alleged mis-communication. However, the medication logs were signed off, indicating that all residents had been assisted with receiving their medication. Records review demonstrated that the Executive Director reported this incident to LPA Kassandra Lopez on 12/01/2021. Interviews revealed that the residents’ primary care physician had been notified and residents were monitored for any adverse reactions.

Based on the information obtained, there is sufficient evidence to support the claim that staff mismanaged medication. This allegation is deemed Substantiated at this time.

Regarding the allegation: Failure to report unusual incidents

It was alleged that incidents were transpiring in the community, yet they were not being reported to Community Care Licensing. An interview revealed that whereas staff observing unexplained bruising on residents, staff admitted to not submitting unusual incident reports to Community Care Licensing. A review of internal facility documents revealed that Resident #1 was observed with unexplained bruising on 01/27/2021, 03/08/2021, and 03/14/2021. Resident #2 was hospitalized on 11/22/2020. Resident #3 had unexplained bruising and/or a skin tear on 1/06/2021, 2/15/2021, and 03/08/2021. There were no submitted incident reports for the above-mentioned occurrences. Lastly, a file review revealed that the community did not submit incident reports from May 2021 – the end of October 2021, with the exception of one report submitted in August 2021.

Based on the information obtained, there is sufficient evidence to support the claim that the facility failed to report unusual incidents. This allegation is deemed Substantiated at this time.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):
Exit interview conducted, today's reports and appeal rights were reviewed and issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2021

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20210308144820

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: 12/05/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/07/2021 Section Cited CCR 87465(a)	1 2 3 4 5 6 7	87465(a)(5) Incidental Medical and Dental Care. The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Administrator agreed to do the following: 1. The staff in question was let go, and no longer works at the community. 2. An in-service was held with medication technicians. Sign-in sheet and appropriate documents to be submitted 12/07/2021
	8 9 10 11 12 13 14	Based on interviews and record review, the licensee did not comply with the section cited above, as residents did not receive the evening dosage of medication on 11/28/2021, which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
Type B 12/07/2021 Section Cited CCR 87211(a)(1)(A-D)	1 2 3 4 5 6 7	87211 Reporting Requirements (a) (1) (A-D) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below......	1 2 3 4 5 6 7	The Administrator shall review Regulation 87211 and submit a written memo of understanding of the regulation to CCL by 12/07/2021
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on record review and interview, the licensee failed to comply with the section cited above as the facility failed to submit written reports as required, which poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14

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: 12/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2021

LIC9099 (FAS) - (06/04)

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