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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 04:39:32 PM


Document Has Been Signed on 05/12/2023 04:39 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:
04:50 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 02/25/2020. LPA Lopez met with Administrator Joey Alvarado and the reason for visit was explained.

On 02/25/2020, from 10:25 a.m. to 12:15 p.m., 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 02/21/2020. LPA Perera met with Business Office Manager Michelle Greenberg and Health and Wellness Director Vivian Reyes. The death report received reflected that Resident #1 (R1) was transported to the hospital on 01/30/2020 after sustaining a fall on the sidewalk outside the facility. R1 died at Los Robles Hospital on 02/18/2020 after being taken off the ventilator on 02/17/2020. During the facility visit, LPA Perera conducted a file review at 10:43 a.m. and obtained pertinent documentation relating to the incident. LPA also conducted a brief interview with Health and Wellness Director to obtain additional information at 10:59 a.m. LPA determined that further investigation was needed, and the case was referred to Community Care Licensing Investigation's Branch (IB) Investigator Joseph Balarie.

Investigator Balarie conducted an interview with Troy Byington, Facility Executive Director, on 03/10/2020 at approximately 9:40 a.m., and with facility staff and residents from approximately 11:00 a.m. to 12:10 p.m.; on 03/11/2020 at approximately 10:00 a.m. with R1’s conservator; on 04/10/2020 from approximately 1:10 p.m. to 2:00 p.m. with facility staff; and on 04/14/2020 at approximately 10:00 a.m. with Los Robles Regional Medical Center Doctor Elise L. Bukont. Facility records and medical records were also obtained and reviewed.

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
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 4


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’s Physician Report, dated 03/14/2019, stated that R1 should be escorted by staff due to cognitive impairment. R1 was diagnosed with Dementia, the loss of intellectual functioning “such as thinking, remembering, reasoning, exercising judgement and decision making”. According to R1’s Physician Report, R1 should not have been allowed to leave the facility unattended. R1 was also prescribed Plavix, a blood thinner which reduces the ability for blood to clot causing blood to leak out and take longer to clot.

The Unusual Incident/Injury Report stated, on 01/30/2020, at approximately 2:30 p.m., a caregiver notified facility staff that R1 was outside the building. Two caregivers saw R1 walking on the sidewalk, 0.2 miles from the facility and were about to escort R1 back to the facility. Before the caregivers could reach R1, R1 tried to turn, lost balance and fell on face on the sidewalk. R1 had blood coming out of nose and an abrasion on left knuckle. R1 was alert and complained of pain on nose.

R1 was brought to the Emergency Department. R1 was noted to have altered mental status and was intubated for airway protection. R1 was subsequently admitted to the ICU. R1 was diagnosed with having a subarachnoid hemorrhage (bleeding within the subarachnoid space, which is the area between the brain and the tissue covering the brain), and a C2 cord contusion. Medical notes stated that it is unclear if R1 had a bleed and then passed out or if the fall resulted in R1’s head injury. There is minimal external trauma on examination and clinical suspicion is that R1 had a bleed then fell. R1 was intubated and maintained on supportive care. R1’s family elected to initiate comfort care only and admitted R1 to inpatient hospice on 02/17/2020. R1 was compassionately extubated and passed away 02/18/2020 at 3:10 p.m. R1’s Certificate of Death indicated R1 died from complications of craniocervical trauma and left rib fractures.

The investigation revealed that facility staff were unaware R1 left the facility unattended on 01/30/2020. Furthermore, the Facility Executive Director (former), Troy Byington, was unaware of R1’s physician report that indicated R1 was not allowed to leave the facility unattended. On 03/10/2020, during a visit to the facility, Investigator Balarie observed no staff near the front door. Facility staff were busy with the duties of the day and seemed to not notice who entered and left the facility including the sign-out sheet. Based on information and documentation obtained during the investigation, the Department determined that lack of care and supervision by the facility led to the fall and hospitalization of R1.

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)
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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: 05/12/2023
NARRATIVE
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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 deficiency is 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 4
Document Has Been Signed on 05/12/2023 04:39 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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87464(f)(1) Basic Services. (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code Section 1569.2(c).
This requirement is not met as evidenced by:



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Licensee will submit a written action plan regarding proper resident care and supervision to CCL by POC due date 05/19/2023.
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Based on interviews and records review, the licensee did not comply with the section cited above. R1 was not provided the proper supervision to ensure resident's safety. R1 left the facility unassisted, which led to a fall resulting in injuries and hospitalization, which posed an immediate health and safety risk..
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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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87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified... (1) Knowledge of the requirements for providing care and supervision appropriate to the residents. This requirement is not met as evidenced by:

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Administrator (former) Troy Byington no longer works at facility. No plan of correction at this time.
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Based on interviews and records review, the licensee did not comply with the section cited above.The Administrator (former) was unaware of R1’s physician report that indicated R1 was not allowed to leave the facility unattended, posing an immediate health and safety risk to R1.

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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)
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