197608878-12-22-2023-29-AS-DPEA-CYZNKV-20231230093233

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608878
Report Date: 12/22/2023
Date Signed: 12/22/2023 10:13:13 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
01/21/2022 and conducted by Evaluator Martha Arroyo

COMPLAINT CONTROL NUMBER: 29-AS-20220121142026

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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Questionable death.
Medications are not being administered as prescribed.
Insufficient staffing.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Martha Arroyo conducted an unannounced subsequent complaint inspection to the above facility. The purpose of the visit is to deliver findings for an investigation initiated by LPA M. Arroyo on 01/24/2022. During today’s visit, LPA met with Executive Director, Joeyvic Alvarado and the reason for the visit was explained.

During the initial inspection, LPA met with Executive Director Joeyvic Alvarado and obtained pertinent documents relevant to the investigation. On 02/15/2022 between 10:44 a.m. and 2:30 p.m., LPA KaSandra Lopez conducted a subsequent inspection and conducted interviews with three (3) staff members and one (1) resident. Additional interviews were also conducted with two (2) staff in July 2023.

(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 4

Control Number 29-AS-20220121142026

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...)

The allegations of ‘Questionable Death’ and ‘Insufficient Staffing’ alleges when Resident #1 (R1) passed away they were already stiff and cold when they were found. Furthermore, it is alleged that staff did not assist R1 properly when they were needing assistance the day prior to R1’s death. It is also alleged that R1 was not checked during the night prior to death, due to only one staff member working on the night shift.

On 01/13/2022, the Administrator submitted a Death Report (LIC 624) for R1 stating on 01/11/2022 at approximately 9:00 a.m., Staff #1 (S1) observed R1 to be unresponsive in their bed. Cardiopulmonary Resuscitation (CPR) was performed and 9-1-1 was contacted. R1 was last seen responsive around 6:00 a.m. The Death Certificate for R1 was obtained. The hour of death noted was 7:40 a.m. The immediate cause of death listed was Cardiopulmonary Arrest, mins. The underlying causes of death were listed as Chronic Hypoxic failure, months, Acute on Chronic Heart Failure, years, and Pulmonary Emphysema, years. The Department requested a copy of R1’s autopsy report but one was not available for review. Facility record review revealed R1 had a diagnosis of Congestive Heart Failure, COPD, and Mild Cognitive Impairment. R1’s most recent needs and service plan dated 10/12/2021, indicated R1 was independent with all aspects of R1’s oxygen use and was primarily independent except for assistance with medications.

Interviews conducted revealed the day before R1’s passing on 01/10/2022, R1 only drank orange juice for breakfast which was normal and only had lunch. Additionally, R1 was observed to be in bed during meal service delivery approximately around 12:00 p.m. Staff interviews also reflected that R1 stated they “tired and not feeling well” however, this was nothing unusual from R1’s day to day behavior. Staff also reported R1 appeared to be in pain however, R1 was breathing normal and was not observed to be struggling with breathing. Additionally, it was revealed R1 used oxygen every day and night. Moreover, medication records reviewed revealed R1 received their scheduled dose of Oxycodone/Acetaminophen at 8:00 a.m. and 2:00 p.m. on 01/10/2022.

(Report Continued from LIC 9099...)

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 4

Control Number 29-AS-20220121142026

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...)

During the interview with S1, they could not recall the time they went into R1’s room to give them their medications but said they start their day at 6:00 a.m. and it was before breakfast. S1 stated when they entered the room, they found R1 in bed, unconscious with no vitals. S1 stated they called 9-1-1 and were asked to perform CPR which they did until paramedics arrived. S1 stated R1 was cold and purple when they found R1. S1 stated R1 used oxygen but could not recall if it was on or not when they found R1. S1 stated R1 had a decline in health prior to death but R1 had no sudden medical changes. R1 was pronounced deceased by paramedics. Additional interviews with staff revealed, approximately between 6:00 a.m. and 7:30 a.m. they were advised that S1 needed assistance with R1. When they arrived S1 was on the phone with paramedics and was being directed to perform CPR. Staff stated they did not observe any obvious trauma to R1 but could tell by the color of their skin that they had passed away. The overnight staff interview revealed R1 was last check between 4:00 a.m. and 4:30 a.m. and was observed to be breathing and sleeping in their bed. During the interview the overnight staff stated they check on all the residents at night.

Interviews and email correspondences with Executive Director, Joey Alvarado revealed although R1 was not receiving hospice care, R1 was declining in health leading up to their death, including eating less and having more pain. The Administrator stated R1 was checked at 6:00 a.m. as part of the morning routine and was observed to be waking up. When staff went into R1’s room for the morning medication pass they observed R1 to be in bed unresponsive and 9-1-1 was called.

Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegations may have happened or is valid, there is insufficient evidence to support that R1’s death was a result of staff neglect. Additionally, there is also insufficient evidence to support the allegation of facility was not staffed sufficiently resulting in R1 not being checked during the night shift. Therefore, these allegations are 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 4

Control Number 29-AS-20220121142026

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...)

The allegation of ‘Medications are not being administered as prescribed’ allege Resident #2’s (R2) medication Warfarin is not being administered to R2 correctly. The reporting party stated one of the errors was documented in R2’s progress notes. During the interview with R2 on 02/15/2022, R2 reported no issues or concerns with medications or not receiving their medications correctly. On 02/15/2022, LPA Lopez reviewed medications and records for R2.

Record review revealed R2’s Warfarin dosing is contingent on laboratory results and doctor’s orders. During the interview with medication technician staff, they stated they were not aware of any issues with R2 getting the correct dose of Warfarin. Staff stated the issue they have been having is the outside company who sends the facility the medication administration records (MAR) is not updating the MAR with the correct dose when it changes but stated the resident is getting the correct dose. The LPA reviewed the progress notes for R2 and did not see any documented medication errors written by staff. The LPA also reviewed medications and medication records for R2 on 02/15/2022 and did not observe any medication errors. Based on the information obtained, there is insufficient evidence to support the allegation of Medications are not being administered as prescribed 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)

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