197608878-9-14-2022-29-AS-KLOZ-CJ9VMV-20220914163409

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608878
Report Date: 09/14/2022
Date Signed: 09/14/2022 04:35:59 PM

Document Has Been Signed on 09/14/2022 04:35 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
ADMINISTRATOR:	JOEYVIC ALVARADO		FACILITY TYPE:	740
ADDRESS:	5217 CHESEBRO RD		TELEPHONE:	(818) 991-3544
CITY:	AGOURA HILLS	STATE: CA	ZIP CODE:	91301
CAPACITY:	185	CENSUS: 95	DATE:	09/14/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:20 AM
MET WITH:	Joey Alvarado		TIME COMPLETED:	04:40 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Required - 1 Year inspection at the facility today. Today's annual has a specific emphasis on infection control practices and procedures. The LPA met with Administrator Joey Alvarado at 11:32 AM and explained the reason for today's visit. The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. At 12:49 PM the LPA and Administrator toured the secured memory care unit. There are currently 29 residents in memory care. The LPA observed three caregivers and one medication tech in the memory care. The Memory Care Coordinator and the Memory Care Health Services Director were also observed. A random selection of five resident rooms were observed. Smoke alarms and carbon monoxide detectors were tested and operational and hot water measured between 105.8 and 111.2 degrees F. During the tour at 1:02 PM, bedroom #133 was observed to be unlocked with over the counter stool softener and loose pills in a bag in their bedroom and bathroom. Record review and interviews revealed Resident #1 (R1) does not have memory impairment and is able to manage their own medications but their spouse, Resident #2 (R2) and other residents in the memory care unit, including Resident #3 (R3) have a diagnosis of dementia and cannot have access to items that could pose a danger, including medications. The items were secured during the inspection. The medication room was observed at 1:29 PM and items that could pose a danger were secured. At 1:43 PM, the assisted living medication room was observed. Items that could pose a danger were secured. A random selection of four resident rooms in assisted living were observed. Smoke alarms and carbon monoxide detectors tested were operational. The hot water temperature measured between 107.6 and 111 degrees F. The signal system was tested and operational. Fire extinguishers observed were fully charged and last serviced on 05/23/2022. At 2:03 PM the dinning room and kitchen was observed. The facility has a sufficient supply of perishable and non-perishable food, including emergency water. Report continued on LIC 809-C.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra Lopez	TELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/14/2022

NARRATIVE

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Common room spaces and furniture were observed to be in good condition. The LPA observed the required postings upon entry. The patios are equipped for resident use. At 2:39 PM the LPA reviewed facility records.

INFECTION CONTROL: During today’s visit, the LPA reviewed the facility’s infection control practices with the Administrator. Upon entry, the facility has a central entry point for symptom screening and sanitation station. All facility staff were observed wearing masks. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility has appropriate plans in place in the event of clients and/or staff are showing symptoms of COVID or testing positive for COVID.

The following deficiency was cited from the CA Code of Regulations. See LIC 809-D. Exit interview and report reviewed with the Administrator. A copy of the report and appeal right were emailed.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra Lopez	TELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/14/2022 04:36 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(2)

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above as at least two resident out of 29 in the memory care have Dementia and over the counter medications were being stored in an unlocked memory care unit resident room which poses an immediate health and safety risk to other memory care residents in care.
	POC Due Date: 09/19/2022
	Plan of Correction
1 2 3 4	The medications were secured in the medication room during the inspection. The Administrator agrees to get the resident a lock box for their medications and conduct an in-service training with staff regarding regulation 87705 and ensuring the resident keeps their medications inaccessible to other residents in care at all time. The plan of correction will be submitted by 09/19/2022.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra Lopez	TELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022

LIC809 (FAS) - (06/04)

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