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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608878
Report Date: 09/14/2022
Date Signed: 09/14/2022 04:37:55 PM


Document Has Been Signed on 09/14/2022 04:37 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 HILLSFACILITY NUMBER:
197608878
ADMINISTRATOR:JOEYVIC ALVARADOFACILITY TYPE:
740
ADDRESS:5217 CHESEBRO RDTELEPHONE:
(818) 991-3544
CITY:AGOURA HILLSSTATE: CAZIP CODE:
91301
CAPACITY:185CENSUS: 95DATE:
09/14/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Joey AlvaradoTIME COMPLETED:
04:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Case Management - Incident inspection pertaining to a self-reported incident report received. The LPA met with Administrator Joey Alvarado at 11:32 AM and explained the reason for today's inspection.

On 09/01/2022, Community Care Licensing Division (CCLD) received a self-report of Suspected Adult/Elder Abuse pertaining to Resident #1 (R1) and Staff #1 (S1). On 08/27/2022, it was reported to the Memory Care Health Services Director, Guadalupe de Los Santos that S1 was observed to be be verbally abusive to R1. On 08/30/2022, video footage of the incident in the memory care dining room was observed by the Administrator and the Health and Wellness Director Alex Alvarado and S1 was placed on administrative leave. The Administrator conducted an internal investigation including interviewing R1, S1, Staff #2 (S2), Staff #3 (S3), and Staff # 4 (S4). The Administrator also cross reported to law enforcement (report number was provided) and the long term care ombudsman. Once the internal investigation was concluded, S1's employment was terminated. The family member of R1 was also notified of the incident.

During today's visit, the LPA reviewed the video footage, which has no sound, and conducted interviews with the Administrator, the Memory Care Health Services Director, Staff #3 (S3), and Resident #1 (R1). Records were also reviewed. No citations are being issued at this time. The LPA may return for a follow up for further investigation if needed.

Exit interview conducted. A copy of the report was issued.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (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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