197608878-12-22-2023-29-AS-DPEA-CZXV72-20240129151025

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608878
Report Date: 12/22/2023
Date Signed: 12/22/2023 10:11:33 AM

Substantiated

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
09/16/2022 and conducted by Evaluator Martha Arroyo

COMPLAINT CONTROL NUMBER: 29-AS-20220916125453

FACILITY NAME:	MEADOWBROOK AT AGOURA HILLS		FACILITY NUMBER:	197608878
ADMINISTRATOR:	JOEYVIC ALVARADO		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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Insufficient staffing

INVESTIGATION FINDINGS:

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On 09/21/2022, LPA Lopez initiated the investigation and conducted interviews with four staff members and the Administrator, reviewed records, and conducted a physical plant tour of the memory care between 12:35 p.m. and 3:30 p.m.

The allegation of Insufficient staffing alleges there have been numerous falls in the memory care unit due to insufficient staffing, as there are days there are only two caregivers on shift which is insufficient. A review of the staff schedule during the month of August and September 2022, revealed during the AM shift there are three (3) caregivers and one (1) med tech scheduled, during the PM shift there are three (3) caregivers and one med tech scheduled, and during the NOC shift there are two (2) caregivers and one (1) med tech scheduled. The census in the memory care is 28 residents.

(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)

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Control Number 29-AS-20220916125453

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 809...)

During the interview with the Administrator Joeyvic Alvarado, she stated Resident #1 (R1) had a fall on 08/15/2022 and went to the hospital. When the resident was discharged the family opted to move them to a board and care and where R1 subsequently passed away. The Administrator showed the LPA surveillance footage of R1 when they fell. The LPA observed the resident to be walking in the hallway when they pulled on their sweater causing them to lose their balance and fall. Video footage went on to show that staff was nearby the resident when they fell and provided aid to the R1 right away. The Administrator was not aware of R1 having any other recent falls. Interview with a staff present near R1 when they fell stated R1’s fall had nothing to do with staffing. They said R1 was agitated that day and they just happened to fall.

Additional interviews with all four staff revealed that there are times when there are only two caregivers during the day shift which makes it difficult to care for the residents, especially when assisting residents who are a two person assist. Interviews also revealed there are some days three caregivers is not enough either to assist residents because that only leaves one person on the floor.

The Administrator stated there are always three caregivers scheduled on shift during the day but there are times when a staff will call out sick and there will be only two caregivers on shift. The Administrator stated it may take an hour or two for agency staff to arrive although a manager will stay and assist, or the medication technician will assist until more staff are available.

Based on the information obtained, although there is not sufficient evidence to support insufficient staffing resulted in resident falls, staff interviews revealed there are times when they only have two caregivers on shift which is insufficient to meet the residents needs. Therefore, the allegation of Insufficient staffing at the time the complaint was filed 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)

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Control Number 29-AS-20220916125453

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 A 12/22/2023 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet residents’ needs. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Licensee has agreed to review regulation 87411 and submit a statement of understanding to CCL no later than 12/29/2023.
	8 9 10 11 12 13 14	Based on interviews, the licensee did not comply with the section cited above as interviews revealed there are times when only two caregivers are on duty in the memory care with 28 residents which poses a potential health and safety risk for residents in care.	8 9 10 11 12 13 14
	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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