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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608878
Report Date: 05/12/2023
Date Signed: 05/12/2023 04:43:19 PM


Document Has Been Signed on 05/12/2023 04:43 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: 98DATE:
05/12/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:39 PM
MET WITH:Joey AlvaradoTIME COMPLETED:
04:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) KaSandra Lopez conducted a Case Management - Incident visit to issue final findings and citations related to the initial Case Management - Incident visit conducted on 02/20/2020. LPA Lopez met with Administrator Joey Alvarado and the reason for the visit was explained.

On 02/20/2020, from 9:15am to 12:40pm, LPA D. Perera conducted an unannounced Case Management - Incident visit to the above facility. The purpose of the visit was to follow up on a Death Report submitted to the Department on 02/17/2020. It was reported that on 02/13/2020, at approximately 6:25pm, Resident #1 (R1) was found on the bathroom floor unresponsive with weak and irregular pulse. 911 was contacted and arrived at the scene at 6:30pm and attempted CPR however, R1 was pronounced deceased at 6:45pm.

LPA Perera met with Administrator/Executive Director Troy Byington and explained the reason for the visit. On 02/19/2020, the LPA contacted the facility administrator and requested additional information regarding the incident. Additional documentation was obtained and reviewed by LPA. During the 02/20/2020 visit, LPA Perera conducted a file review between 9:30am - 10:15am and obtained pertinent documentation related to the incident. LPA also conducted a brief tour of the facility memory care unit at 10:20am. Prior to issuing a final licensing report, LPA determined that further investigation was needed, and the case was referred to Community Care Licensing Investigations Branch (IB) Investigator Joseph Balarie.

Investigator Balarie conducted interviews with Troy Byington, Administrator/Executive Director on 03/10/2020 at approximately 9:40am; facility residents at approximately 11:30am to 12:10pm; and Staff #1 (S1) on 03/11/2020 at approximately 8:40am. Facility records, medical records, and death certificate were also obtained and reviewed.

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: 05/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5


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: 05/12/2023
NARRATIVE
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R1 was admitted to the Assisted Living portion of the facility on 04/10/2019. R1’s Physician Report, dated 04/09/2019, stated R1’s diagnosis as Type 2 Diabetes and hypertension. Other conditions included chronic kidney disease and major depression. R1 suffered from mild cognitive impairment and was not able to manage own treatment, medication, and medical equipment. The report listed R1’s physical health status as “good”. On 07/27/2019, R1 had a change of condition and was moved from Assisted Living to the Memory Care Unit. The facility did not submit any appraisal, updated assessments or care plans for R1.

From 10/17/2019 to 10/24/2019, R1 was admitted to Los Robles Regional Medical Center for acute hypoxia respiratory insufficiency and Congestive heart failure exacerbation. The medical records documented R1 had multiple medical problems including Chronic Kidney Disease stage IV, Dementia, Insulin dependent diabetes, Hypertension, Hypersensitivity Lung Disease, Bronchiectasis and presented for evaluation of Dyspnea and Hypoxia. On 10/31/2019, R1 was followed up at UCLA Health Simi Valley Cardiology clinic and instructed to return in 3 months. On 11/05/2019, R1 was seen at UCLA Health System Thousand Oaks Interventional Pulmonology for post hospital follow up and consultation. Diagnoses were listed as Bronchiectasis, Pulmonary nodules, and Chronic diastolic heart failure. R1 was referred for a PET and a CT chest scan and to follow up in 3 months. R1 was scheduled to see the primary care physician (PCP) on 11/06/2019 and the Cardiologist on 11/21/2019, however, the facility did not submit those records.

On 02/13/2020 at 4:05pm, the med tech/Staff #1 (S1) checked R1’s blood sugar, which was 135, and two (2) units of Humalog insulin was given. A caregiver reported R1 had difficulty breathing despite sitting down. The S1 called R1’s doctor and they both agreed R1 should go to the emergency room. R1 declined and stated they were feeling better and went out for a scheduled radiology appointment. At 5:45pm, R1 returned to the facility and told the caregiver they felt nauseous. Then S1 encouraged R1 to go the emergency room, R1 declined again. R1’s family was notified, but no document indicated the doctor was called. At 6:24pm, R1 was found unresponsive on the floor of R1’s bathroom. R1’s pulse was irregular and weak. 911 was called. At 6:28pm, it was discovered that R1 did not have a DNR (Do Not Resuscitate) and S1 began CPR. At 6:30pm, paramedics arrived and performed CPR with no success. At 6:45pm, R1 was pronounced dead. The Certificate of Death from County of Los Angeles indicated the primary cause of death was Chronic Renal Failure, and the secondary cause was Diabetes Mellitus Type II

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: 05/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
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: 05/12/2023
NARRATIVE
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Information obtained from interviews with the Administrator/Executive Director stated that S1 should have followed facility policy and immediately called both 911 and R1’s family when R1 experienced nausea and had difficulty breathing. S1 was written up for not calling 911 soon enough and stated if they could go back and handle this incident all over again, they would have called 911 immediately after noticing R1 struggle to breathe. Information and evidence obtained during the investigation sufficiently supports that facility staff failed to seek timely medical attention for R1.
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A $500 immediate civil penalty is assessed today. The Administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) or (f).

Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 809-D)

Exit interview conducted, civil penalty issued, appeal rights discussed, and a copy of this report issued.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 05/12/2023 04:43 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: 05/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/19/2023
Section Cited

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87465 Incidental Medical and Dental Care (g)The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis…. This requirement is not met as evidenced by:
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Licensee will have staff complete training on timely medical treatment and emergency procedures. Submit proof of correction to CCL by 05/19/2023.
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Based on interviews, the licensee did not comply with the section cited above. R1 was not provided timely medical treatment on 02/13/2020 which led to R1’s death, which posed an immediate health and safety risk to residents in care.
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An immediate civil penalty of $500 is warranted in accordance with California Health and Safety Code Section 1569.49(c).
Type A
05/19/2023
Section Cited

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87628(a) Diabetes (a)The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing…and is able to administer his/her own medication…, or has it administered by an appropriately skilled professional.

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Licensee will submit plan on how you will ensure glucose testing and insulin injections are performed by an appropriately skilled professional. Submit to CCL by 05/19/2023.

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Based on record review, the licensee did not comply with the section cited above. R1 needed assistance with glucose testing and medication administration, which was performed by a med tech and not an appropriately skilled professional, which posed an immediate health risk...

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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: 05/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 05/12/2023 04:43 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: 05/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/19/2023
Section Cited

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87705(c)(5) Care of Persons with Dementia (c) Licensees who accept... residents with dementia shall.... ensuring the following: (5)Each resident with dementia shall have medical assessment,.. at least annually…This requirement is not met as evidenced by:
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Licensee will submit memo of understanding regarding updating medical assessments due to change of condition. Submit to CCL by 05/19/2023



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Based on record review, the licensee did not comply with the section cited above. R1’s condition changed on 7/27/2019 when R1 was moved from AL to the MC Unit. Licensee failed to update R1’s medical assessment, which posed a potential health and safety risk.
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Type B
05/19/2023
Section Cited

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87705(c)(6) Care of Persons with Dementia (c)Licensees who... retain residents with dementia...responsible for ensuring the following: (6) Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals.
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Licensee will submit memo of understanding regarding updating care plans and appraisals due to change of condition. Submit to CCL by 05/19/2023.
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Based on record review, the licensee did not comply with the section cited above.
This requirement is not met as evidence by:
The licensee failed to develop a care plan to meet R1’s needs and update the care plan when conditions changed, which posed a potential health and safety risk to residents 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: 05/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5