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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608878
Report Date: 02/24/2023
Date Signed: 02/24/2023 03:21:10 PM


Document Has Been Signed on 02/24/2023 03:21 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: 90DATE:
02/24/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Alex Alvarado & Michelle GreenbergTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Case Management Incident inspection at the facility today. The LPA met with Health and Wellness Director (HWD) Alex Alvarado and Business Office Manager Michelle Greenberg and explained the reason for the inspection.

On 02/21/2023, Community Care Licensing (CCL) received an Unusual Incident/Injury Report (LIC 624) pertaining to Resident #1 (R1) and Staff #1 (S1). Please note, the Administrator Joey Alvarado submitted the written report to CCL on 02/19/2023, but due to the report being received over the weekend, and Holiday on Monday, the report was not reviewed until 02/21/2023. The report stated on 02/19/2023, Staff #2 (S2) observed R1 to have superficial peeling of the skin on their right upper back. S2 reported this to the med-tech on duty who then reported to HDW Alex Alvarado who then investigated the incident. Interviews revealed that on 02/12/2023, S1 used a bucket of hot water from the kitchen to bathe R1 due to R1 not having any hot water in their shower and failed to test the water prior to using on the resident. S1 noticed redness on R1's right upper back but failed to report to a supervisor. The HWD notified R1's physician of the incident. R1 was taken to urgent care by the request of R1's family member and returned back the same day with a topical prescriptions to be applied to the area.

On 02/23/2023, the LPA spoke with Administrator Joey Alvarado regarding the incident. She stated R1 was sent to the urgent care on 02/19/2023 and was diagnosed with a burn of unspecified degree of upper back and was prescribed prescription medication to be applied to the injury. The Administrator emailed this document to the LPA. The Administrator stated when S1 was interviewed they conveyed the incident was an accident and they had no ill intent. The Administrator stated S1 was placed on leave initially when they were aware of the incident and then terminated on 02/22/2023. The Administrator stated R1's room does have an issue with maintaining hot water temperature which maintenance is currently working on. The Administrator stated the part needed to fix the issue is currently on order. In the interim, R1 was moved to another room until the repair can be made. Report continued on LIC 809-C.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2023
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: 02/24/2023
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During today's inspection, the LPA conducted file review for R1 and S1 beginning at 12:48 PM. The LPA also conducted an interview with R1 at 1:17 PM. During the interview with R1, they stated S1 used a bucket of hot water to rinse R1 off in the shower due R1's shower not having any hot water. R1 stated when S1 poured the water on them, they scream that the water was hot and S1 stopped and apologized. R1 said they had cold water that whole week in their room and stated the water would get warm and then get cold right away. R1 stated in their current room the water temperature was fine and they currently have no pain due to the injury.

During the inspection, the LPA tested the water temperature in R1's current room with maintenance and in their previous room. In R1's current room, the LPA measured the hot water at 121.6 degrees F. and maintenance measured at 120 degrees F. The parties agreed to turn down the water heater a bit to error on the side of safety. The water temperature in R1's prior room measured at 106 degrees F. by both parties and then declined quickly as soon as it hit 106 degrees F. Record review revealed R1's service plan has been updated to reflect care needed due to the injury. On 02/20/2023, an In-service training was conducted regarding "Skin integrity and appropriate water temperature" with all staff members.

Based on the information obtained, there is sufficient evidence to support a deficiency is warranted as R1 sustained an injury as a result of S1 using untested hot water to bathe R1. The following deficiency was cited (See LIC 809-D) from CA Code of Regulations, Title 22, Division 8. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/24/2023 03:21 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: 02/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/24/2023
Section Cited

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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement is not met as evidence by:
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The Administrator terminated S1, relocated R1 to a new room, and conducted an in-service training with all staff on 02/20/2023. Plan of correction is cleared.
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Based on interview and record review, the licensee failed to comply with the section cited above, as R1 sustained injury due to S1 using hot water when bathing R1 which is an immediate health risk to R1 in care.
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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 PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2023
LIC809 (FAS) - (06/04)
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