197608878-12-22-2023-29-AS-DPEA-CYZNG4-20231230092628

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608878
Report Date: 12/22/2023
Date Signed: 12/22/2023 10:15:12 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/25/2021 and conducted by Evaluator Martha Arroyo

COMPLAINT CONTROL NUMBER: 29-AS-20211025115308

FACILITY NAME:	MEADOWBROOK AT AGOURA HILLS		FACILITY NUMBER:	197608878
ADMINISTRATOR:	MATAN BURSTYN		FACILITY TYPE:	740
ADDRESS:	5217 CHESEBRO RD		TELEPHONE:	(818) 991-3544
CITY:	AGOURA HILLS	STATE: CA	ZIP CODE:	91301
CAPACITY:	185	CENSUS: 100	DATE:	12/22/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Joeyvic Alvarado		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Staff hit resident
Resident bit another resident's leg
Facility did not notify resident's family of incident
Insufficient staffing

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Martha Arroyo conducted an unannounced subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for an investigation initiated by LPA K. Lopez on 11/01/2021. During today’s visit, LPA met with Executive Director, Joeyvic Alvarado and the reason for the visit was explained.
During the initial visit on 11/01/2021, LPA met Regional Director Joann Gange and Assistant Administrator Walter Cline. During the visit, the LPA conducted a physical plant tour of the memory care unit beginning at 12:54 PM with Walter Cline. Between 1:08 PM and 2:40 PM the LPA conducted interviews with Staff #1 (S1) and Staff #2 (S2). The LPA attempted to interview Resident #1 (R1), Resident #2 (R2) and Resident #3 (R3) during this time but was unable due to their cognitive impairments or due to the resident sleeping. At 3:07 PM the LPA reviewed facility records and obtained pertinent copies of records. On 11/10/2021, the LPA conducted interviews with two staff members during a visit for another complaint investigation and obtained information for this investigation also.
(Report Continued on LIC 9099C...)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 7

Control Number 29-AS-20211025115308

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/22/2023

NARRATIVE

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(Report Continued from LIC 9099...)

On 08/11/2023, LPA Lopez conducted a subsequent inspection at the facility. The LPA initially met with Health and Wellness Director Alex Alvarado and explained the reason for the inspection. Administrator Joey Alvarado arrived during the inspection. During the inspection, the LPA conducted a tour of the memory care unit, at 11:32 AM, reviewed facility records and interviewed the Administrator and Health and Wellness Director.

Allegation: Staff hit resident.

The allegation alleges Staff #3 (S3) hit Resident #1 (R1). The Interview with Regional Director Joann Gange revealed she was not aware of any complaints regarding a staff hitting a resident but about four weeks prior, she was informed by Staff #2 (S2) that R1 was holding the frame of their door and S3 forcefully pushed R1 in their wheelchair into their room. Ms. Gange interviewed S3 and S3 denied the incident but was placed on suspension immediately. Ms. Gange stated she investigated and found out that R1 always holds the door frame when staff are pushing R1 into their room. Ms. Gange said she reviewed the surveillance video afterwards and did not observe S3 pushing R1 forcefully into their room. The LPA was advised during the 11/01/2021 visit that S3 no longer works at the facility.

During the interview with S2, S2 stated they heard a loud noise and went into R1’s room. S2 said when they got there, they observed that S3 had pushed R1 in their wheelchair into R1’s room. S2 stated they did not observe the incident although heard a loud noise and R1 say “ouch”. S2 stated they did not document the incident in writing. The LPA attempted to interview R1 during the investigation but was unable to due to cognitive impairments. On 11/10/2021, the LPA conducted interviews with two staff members during a visit for another complaint investigation and these staff members had no additional information regarding this incident.

Based on the information obtained there is insufficient evidence to support the allegation of S3 hit R1 occurred. Therefore, the allegation is deemed unsubstantiated at this time.

(Report Continued on LIC 9099C...)

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 7

Control Number 29-AS-20211025115308

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/22/2023

NARRATIVE

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(Report Continued from LIC 9099C...)

Allegation: Resident bit another resident's leg.

The allegation of “Resident bit another resident's leg” alleges Resident #2 (R2) bit the leg of Resident #3 (R3) resulting in injury. Record review revealed on 04/07/2021 the facility completed a Report of Suspected Dependent Elder Abuse Report (SOC 341) which stated on 04/06/2021 staff walked into R3’s room and observed R2 pulling on R3’s leg creating a large skin tear. Staff immediately paged for assistance, redirected R2 and called 911. R3 was taken to the hospital and received sutures and returned the next day. The report states R3’s physician and family member was informed. Hospital records reviewed indicated R3 was seen on 04/06/2021 for a skin laceration. Facility progress notes state on 04/06/2021, staff observed a resident scratching and pulling on R3’s leg causing a big skin tear. 911 was called. The administrator notified the family.

During the 11/01/2022 visit, the LPA met with R2 and R3 briefly. R2 was sleeping and R3 was in their bedroom. Both residents reside in the memory care unit and are unable to be interviewed due to cognitive impairment. Interview with Ms. Gange revealed she had no information regarding a biting incident between R2 and R3 and was only aware of R2 scratching R3 and due to R3 having fragile skin they called 911 because they could not stop the bleeding. Ms. Gange said the family members of R3 are aware of the incident because they brought it up when discussing R3’s history with Ms. Gange. Staff interviewed were either not present when the incident occurred or did not work at the facility when the incident occurred, although no staff were aware of R2 being physically aggressive to other residents prior to this incident and R2 only being aggressive with staff members.

Based on the information obtained there is insufficient evidence to support the allegation of Resident bit another resident's leg occurred. Therefore, the allegation is deemed unsubstantiated at this time.

(Report Continued on LIC 9099C...)

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 7

Control Number 29-AS-20211025115308

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/22/2023

NARRATIVE

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(Report Continued from LIC 9099C...)

Allegation: Facility did not notify resident's family of incident

The allegation of Facility did not notify resident's family of incident alleges the family members of R3 were not made aware of the 04/06/2021 incident between R2 and R3 until two weeks after the incident occurred. Record review revealed the facility completed a report of Suspected Dependent Elder Abuse form on 04/07/2021 and cross reported to the Ombudsman’s Office and Community Care Licensing. On this report, it states the resident’s daughter and physician were notified of the incident. Medical records from West Hills Hospital also indicate that the resident was hospitalized on 04/06/2021 for a laceration to their leg and discharged on 04/07/2021. Hospital Admissions records had R3’s daughter listed as the resident’s contact person. Furthermore, progress notes for R3 indicate on 04/06/2021, a former administrator was notified of the incident they contacted the family to advise 911 had been contacted for R3 due to the incident. During the interview with Ms. Gange, she said the family members of R3 were aware of the incident because they brought it up when discussing R3’s history in the past. Based on the information obtained, there is insufficient evidence to support the allegation of Facility did not notify resident’s family of incident. Therefore, the allegation is deemed unsubstantiated at this time.

Allegation: Insufficient staffing

The allegation of Insufficient staffing alleges the facility is short staffed in the memory care. During the 11/01/2021, visit the LPA conducted interviews with two memory care staff members who stated on this day they were fully staffed in the memory care. Interviews revealed it is harder when they have agency staff working because they have to teach them about the residents but lately there have been 2-3 permanent staff on shift. Interview also revealed there were issues in the past with insufficient staff but currently there is not a problem. Review of the staff schedule revealed one med tech and three caregivers scheduled during the day shift and two caregivers and one med tech on the overnight shift. Based on the information obtained, there is insufficient evidence to support the allegation of Insufficient staffing occurred. Therefore, the allegation is deemed unsubstantiated at this time.

Exit interview conducted. A copy of the report and appeal rights provided

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 7

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/25/2021 and conducted by Evaluator Martha Arroyo

COMPLAINT CONTROL NUMBER: 29-AS-20211025115308

FACILITY NAME:	MEADOWBROOK AT AGOURA HILLS		FACILITY NUMBER:	197608878
ADMINISTRATOR:	MATAN BURSTYN		FACILITY TYPE:	740
ADDRESS:	5217 CHESEBRO RD		TELEPHONE:	(818) 991-3544
CITY:	AGOURA HILLS	STATE: CA	ZIP CODE:	91301
CAPACITY:	185	CENSUS:	DATE:	12/22/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Joeyvic Alvarado		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Facility did not report staff abusing resident to proper agencies.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Martha Arroyo conducted an unannounced subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for an investigation initiated by LPA K. Lopez on 11/01/2021. During today’s visit, LPA met with Executive Director, Joeyvic Alvardo and the reason for the visit was explained.
During the initial visit on 11/01/2021, LPA met Regional Director Joann Gange and Assistant Administrator Walter Cline. During the visit, the LPA conducted a physical plant tour of the memory care unit beginning at 12:54 PM with Walter Cline. Between 1:08 PM and 2:40 PM the LPA conducted interviews with Staff #1 (S1) and Staff #2 (S2). The LPA attempted to interview Resident #1 (R1), Resident #2 (R2) and Resident #3 (R3) during this time but was unable due to their cognitive impairments or due to the resident sleeping. At 3:07 PM the LPA reviewed facility records and obtained pertinent copies of records. On 11/10/2021, the LPA conducted interviews with two staff members during a visit for another complaint investigation and obtained information for this investigation also.
(Report Continued on LIC 9099C...)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 5 of 7

Control Number 29-AS-20211025115308

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/22/2023

NARRATIVE

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Allegation: Facility is not reporting staff abusing resident to proper agencies

The allegation of facility is not reporting staff abusing resident to proper agencies alleges there was an incident between Staff #3 (S3) and Resident #1 (R1) that was not reported to the appropriate agencies. Record review revealed Community Care Licensing (CCL) was not notified of an alleged incident between S3 and R1. The Interview with Regional Director Joann Gange revealed she was not aware of any complaints regarding a staff hitting a resident but about four weeks prior, she was informed by Staff #2 (S2) that R1 was holding the frame of their door and S3 forcefully pushed R1 in their wheelchair into their room. Ms. Gange interviewed S3 and S3 denied the incident but was placed on suspension immediately. Ms. Gange stated she investigated and found out that R1 always holds the door frame when staff are pushing R1 into their room. Ms. Gange said she reviewed the surveillance video afterwards and did not observe S3 pushing R1 forcefully into their room. Interview of S2 revealed they did not witness the incident but only heard a loud noise R1 say “ouch”. S2 stated they did not document the incident in writing. The LPA was advised during the 11/01/2022 visit, that S3 no longer works at the facility. The LPA inquired why the alleged abuse was not reported to CCL, law enforcement, or LTCO. Ms. Gange said she did not feel the need to document and report it because the nurse did a body assessment and R1 did not have any redness or sign of injury.

Based on the information obtained, there is sufficient evidence to support the allegation occurred. Therefore, the allegation of facility is not reporting staff abusing resident to proper agencies is deemed substantiated at this time.

Exit interview conducted. A copy of the report and appeal rights provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2023

LIC9099 (FAS) - (06/04)

Page: 6 of 7

Control Number 29-AS-20211025115308

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/22/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/29/2023 Section Cited CCR 87211(a)	1 2 3 4 5 6 7	(a) Each licensee shall furnish to the licensing agency such reports as the Department...written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below...	1 2 3 4 5 6 7	The Licensee has agreed to review regulation 87211 and submit a statement of understanding to CCL no later than 12/29/2023.
	8 9 10 11 12 13 14	...This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement was not met as evidenced by:	8 9 10 11 12 13 14	Based on interview and record review, the licensee failed to comply with the section above as the licensee failed to submit a written report to the appropriate agencies regarding the alleged abuse between S3 and R1 which is a potential health and safety risk to residents in care.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2023

LIC9099 (FAS) - (06/04)

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