197608878-8-10-2023-29-AS-DPEA-D2WRHV-20240229120257

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608878
Report Date: 08/10/2023
Date Signed: 08/10/2023 03:50:24 PM

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
11/08/2022 and conducted by Evaluator Kasandra Lopez

COMPLAINT CONTROL NUMBER: 29-AS-20221108114659

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: 94	DATE:	08/10/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Joey Alvarado		TIME COMPLETED:	04:05 PM

ALLEGATION(S):

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Personal Rights: Facility staff have been hitting, pushing, and pulling the hair of multiple residents
Staff is rough with residents when providing incontinent care
Staff are not providing incontinent care timely
Resident is isolated and neglected
Staff does not treat residents with dignity and respect
Staff are not assisting residents with ADLs
Residents have unexplained injuries
Management staff are not following up on abuse reports

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) KaSandra Lopez conducted a subsequent complaint visit to deliver findings for the above allegation. LPA met with Business Office Manager Michelle Greenburg at 11:06 AM initially and explained the reason for the visit. The LPA later met with Administrator Joey Alvarado at 11:50 AM.

On 11/08/2022, the Department received a complaint regarding physical abuse allegations. It was alleged that facility staff have been hitting, pushing, and pulling the hair of multiple residents. The complaint was referred to the Community Care Licensing Investigations Branch (IB) and assigned to Investigator Edward Hector.

On 11/09/2022, from 11:00am to 5:00pm, Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced initial 10-day complaint inspection at the facility. LPA Lopez met with Administrator Joey Alvarado at 11:12am and explained the reason for the inspection. Report continued on LIC 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra Lopez	TELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023

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 5

Control Number 29-AS-20221108114659

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: 08/10/2023

NARRATIVE

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Between 11:12am and 4:30pm the LPA conducted interviews, observed the memory care unit and residents, and reviewed facility records. Copies of pertinent records were also obtained.

On 12/30/2022, from 4:45pm to 5:24pm, Investigator Hector conducted interviews with the Assistant Administrator and residents; on 02/07/2023, from 11:50am to 12:45pm, with the Administrator, staff, and Staff #1 (S1); on 02/08/2023, at 5:55pm, with Staff #2 (S2); on 02/09/2023, from 10:20am to 6:28pm, with former staff, and the Long Term Care Ombudsman (who confirmed their office was notified and aware of the complaint allegations); and on 02/10/2023, at 1:49pm, with staff. The investigator contacted the Los Angeles County Sheriff Department (LASD) Lost Hills station. A review of the LASD records noted no report in their database pertaining to the facility. Additionally, the Investigator reviewed facility file documents related to residents and staff including the facility’s internal investigation documents.

During today's visit, the LPA toured the memory care unit with Health and Wellness Director Alex Alvarado at 10:28 am, met with Resident #4 (R4) at 10:33 am, and interviewed three staff members between 10:42 am and 11:26 am. The LPA also conducted interviews with Alex Alvarado and Administrator Joey Alvarado during the inspection. At 2:18 pm, the LPA conducted an interview with Memory Care Director Guadalupe De Los Santos.

According to the facility’s internal investigation documents, the facility administrators interviewed staff, interviewed residents, and reviewed records in response to the report of abuse by staff. The reporting parting (RP) reported that S1 slapped residents and pulled their hair. It was also reported that S2 slammed Resident #1 (R1) while changing R1. S1 also allegedly pushed Resident #2 (R2) and spoke to R2 using profanity while R2 was in the dining hall. The RP also reported that staff used excessive force against Resident #3 (R3). After completion of the internal investigation, the facility administrators listed “staff nor residents have reported any inappropriate behavior or conduct regarding S2 and found all allegations to be unfounded.” The Administrator summarized the current investigation as staff complaining about each other’s work habits and conduct and stated that her investigation revealed no evidence of abuse. The Administrator reported the alleged abuse to law enforcement. However, law enforcement advised they “did not come out” because the situation appeared to have been resolved.

Report continued on LIC 9099-C.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra Lopez	TELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 29-AS-20221108114659

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: 08/10/2023

NARRATIVE

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During the course of the investigation, Investigator Hector contacted the Sheriff’s Department. The allegations were reported, but LASD did not complete a report regarding the incident. Multiple residents were interviewed and did not disclose any abuse. Interviews were conducted with former staff and current staff. The majority of the staff did not witness any abuse conducted by S1 or S2. Only one former staff stated to have witnessed the alleged abuse. However, the former staff stopped working at the facility three months prior to the current disclosure of abuse. Both S1 and S2 denied the allegations.

The investigation did not provide sufficient evidence to substantiate the allegation of physical abuse, therefore the allegation “Facility staff have been hitting, pushing, and pulling the hair of multiple residents” is deemed Unsubstantiated at this time.

Allegation: Staff is rough with residents when providing incontinent care

The allegation alleges Staff #2 (S2) was rough with Resident #1 (R1) and slammed R1 against the wall when providing incontinent care. On 12/30/2022, Investigator Hector conducted an interview with S2. During the interview S2 denied ever slamming R1 or rough handling any of the residents. Interviews conducted during Investigator Hector's investigation and during today's inspection by the LPA, revealed no reports of S2 being abusive to any residents. Based on the information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation of staff is rough with residents when providing incontinent care

Allegation: Staff are not providing incontinent care timely

The allegation alleges residents are left soiled and wet. The alleged allegations occurred in the memory care unit. During the previous inspection on 11/09/2022, the LPA observed R4 in bed. The Administrator and the Memory Care Director Guadalupe Del los Santos checked R4 and confirmed they were dry and showed the LPA the resident's dry diaper. Staff interviews conducted revealed no issues with residents being left in soiled diapers from a previous shift. Based on the information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation is deemed unsubstantiated at this time.

Report continued on LIC 9099-C.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra Lopez	TELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 29-AS-20221108114659

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: 08/10/2023

NARRATIVE

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Allegation: Resident is isolated and neglected

The allegation alleges R4 is isolated in their room and staff often forgets about the resident. During the previous inspection on 11/09/2022, the LPA observed R4 in bed. The Administrator and the Memory Care Director Guadalupe Del los Santos checked R4 and confirmed they were dry and showed the LPA the resident's dry diaper. During today's inspection, the LPA observed R4 in their room in bed. The resident appeared clean with clean bedding. Due to their cognitive impairment, the LPA was unable to conduct an interview with R4. Interviews with staff revealed the resident is usually brought out of their room daily and taken to the common areas but sometimes R4 will get upset and will want to return back to their room. Staff interviewed denied forgetting about the resident and stated R4 is checked every two hours. Based on the information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation of resident is isolated and neglected is deemed unsubstantiated at this time.

Allegation: Staff does not treat residents with dignity and respect

The allegation alleges S2 uses profanity in Spanish towards the residents when assisting them. During the interview with Investigator Hector, S2 denied using profanity in Spanish when talking with the residents. Other staff interviews conducted by Investigator Hector revealed, most staff denied hearing S2 uses profanity when speaking to the residents. Interviews today revealed no observation of staff using profanity in Spanish towards the residents. Based on the information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation of staff does not treat residents with dignity and respect is deemed unsubstantiated.

Allegation: Staff are not assisting residents with ADLs

The allegation alleges Resident #5 (R5) was left in their pajama shirt from the night before due to S1 failing to change the resident's clothing. During today's inspection and the previous inspection, the LPA observed the residents in the memory care to be groomed and clothed appropriately.

Report continued on LIC 9099-C.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra Lopez	TELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 29-AS-20221108114659

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: 08/10/2023

NARRATIVE

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During today's inspection, the LPA conducted an interview with S1. S1 stated R5 can be resistant to changing and grooming and sometimes will not allow S1 to change R5's clothing. S1 stated when this happens they will leave R5 in their clothing in order to not upset them further but denied intentionally not attending to the resident and not changing their clothes. Interviews with staff revealed no issues or concerns with residents being left in clothing from the night before and not being assisted with ADLs. Based on the information obtained, there is insufficient evidence to support the allegation of occurred. Therefore, the allegation of staff are not assisting residents with ADLs is deemed unsubstantiated at this time.

Allegation: Residents have unexplained injuries

The allegation alleges residents have bruises and cuts from falling that they should not have. Interviews with staff revealed residents have sustained injuries due to falls in the past but staff interviewed did not believe the injuries could have been prevented. Based on the information obtained there is insufficient evidence to support the allegation occurred. Therefore, the allegation of residents have unexplained injuries is deemed unsubstantiated at this time.

Allegation: Management staff are not following up on abuse reports

The allegation alleges reports of abuse were reported to management staff and management did not follow up. Record review revealed on 11/01/2022, Staff #5 (S5) reported alleged abuse to management pertaining to S2 and R2 that occurred on 10/28/2022. S2 was placed on leave and a SOC 341 was completed and cross reported to CCL, LTCO, and law enforcement on 11/01/2022. During the interviews with the Administrator and the Health and Wellness Director they denied not reporting or following up any other alleged allegations of abuse. Based on the information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation of management staff are not following up on abuse reports is deemed unsubstantiated at this time.

Exit interview and report reviewed with the Administrator. A copy of the report and appeal rights provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra Lopez	TELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023

LIC9099 (FAS) - (06/04)

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