197608878-11-10-2021-29-AS-DPEA-CHBQEU-20220815120655

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608878
Report Date: 11/10/2021
Date Signed: 11/10/2021 06:09:35 PM

Unsubstantiated

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
11/02/2021 and conducted by Evaluator Kasandra Lopez

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20211102115349

FACILITY NAME:	MEADOWBROOK AT AGOURA HILLS		FACILITY NUMBER:	197608878
ADMINISTRATOR:	MATAN BURSTYN		FACILITY TYPE:	740
ADDRESS:	5217 CHESEBRO RD		TELEPHONE:	(818) 991-3544
CITY:	AGOURA HILLS	STATE: CA	ZIP CODE:	91301
CAPACITY:	185	CENSUS: 93	DATE:	11/10/2021
		UNANNOUNCED	TIME BEGAN:	11:34 AM
MET WITH:	Joeyvic Alvarado		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Resident hit another resident in care.
Resident did not receive medical treatment for their injury

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced initial 10 day complaint inspection regarding the above allegations. The LPA met with Business Manager Michelle Greenberg and newly appointed Administrator Joeyvic Alvarado at 11:34 AM and explained the reason for today's visit.

During today's inspection, the LPA conducted interviews with Staff #1, Staff #2, Staff #3, and Staff #4, between 10:48 AM and 2:35 PM. The LPA also conducted interviews with Resident #1(R1) and Resident #2 (R2) between 1:10 PM and 1:30 PM. Beginning at 2:13 PM the LPA reviewed facility records.

The allegation of 'Resident hit another resident in care', alleges R1 was hit by another resident and fell to the floor. Record review revealed on 10/21/2021 there was an incident between R1 and R2. R1's interview revealed R1 was hit in the shoulder area by another resident. LPA attempted to interview R2 but was unable to due to their impairments.
Report continued on LIC 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra Lopez	TELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:	DATE: 11/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021

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-20211102115349

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: 11/10/2021

NARRATIVE

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Interviews with staff revealed after dinner, staff responded to a scream by R1 and found R1 in the courtyard on the ground alleging R2 pushed R1. R1 was assessed and the residents were separated. Staff interviews revealed there was no history of R1 or R2 being physically aggressive with each other or with other residents. Record review also did not find any evidence to support this. Staff stated since the incident, they are now watching R2 more carefully. Based on the information obtained, although an altercation may have occurred between R1 and R2, there is insufficient evidence to support the incident was a result of lack of supervision. Therefore, the allegation of 'Resident hit another resident in care' is deemed unsubstantiated at this time.

The allegation of 'Resident did not receive medical treatment for their injury' alleges R1 did not receive medical treatment for their injury due to R1 not having a doctor. Interviews with staff revealed R1 was offered emergency services when the incident occurred but denied these services and denied having any injury. On the day of the incident, the facility nurse observe R1 for injury. Record review revealed on 10/21/2021, R1's physician on file was faxed regarding the incident but the physician returned the fax on 10/25/2021 indicating R1 was no longer their patient. Staff interviews revealed they were not aware of R1 no longer having a physician prior to this. Interviews revealed in the days following the incident, R1 complained of intermittent pain to their shoulder and R1's family was contacted to obtain a new physician for R1. Record review revealed R1 was seen by a physician on 11/3/2021, had an x-ray on 11/8/2021, and seen at an urgent care on 11/9/2021. Based on the information obtained, there is insufficient evidence to support the allegation of 'Resident did not receive medical treatment for their injury' occurred. Therefore, the allegation is deemed unsubstantiated at this time.

Exit interview and report reviewed with Administrator Joey Alvarado. A copy of the report and appeal rights was emailed.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra Lopez	TELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:	DATE: 11/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021

LIC9099 (FAS) - (06/04)

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