<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608878
Report Date: 08/19/2021
Date Signed: 08/19/2021 03:36:13 PM

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:MATAN BURSTYNFACILITY TYPE:
740
ADDRESS:5217 CHESEBRO RDTELEPHONE:
(818) 991-3544
CITY:AGOURA HILLSSTATE: CAZIP CODE:
91301
CAPACITY:185CENSUS: 89DATE:
08/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Matan BurstynTIME COMPLETED:
03:40 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPAs) KaSandra Lopez and Martha Guzman-Chavez conducted an unannounced Required 1 year inspection at the facility today. The LPAs met with Administrator Matan Burstyn and explained the reason for today's inspection.

At 11:05 AM the LPAs and administrator began a physical plant tour. Infection control practices were reviewed with the administrator and observed during the inspection. Required signs were observed during the inspection. The facility's dining room and kitchen were observed. The facility had a sufficient supply of perishable and non-perishable food and food was stored at appropriate temperatures. A random selection of four resident rooms in assisted living were observed between 11:17 AM and 11:44 AM. Smoke alarms were tested in each room and were operational. The water temperature was tested and measured between 119.5 and 111.2 degrees F. The carbon monoxide detector in the dining room was tested and operational. Fire extinguishers observed were fully charged and last serviced on 02/25/21. At 11:44 AM the medication room was observed. Medication is centrally stored and inaccessible to residents in care. Medications for two residents were observed to be administered as prescribed and recorded on the centrally stored medication records. First aid supplies were reviewed and complete. Beginning at 12:02 PM the memory care unit was observed. Two resident rooms were observed. Smoke alarms in the rooms were observed to be functional and hot water measured between 106 and 109.4 degrees F. At 1:06 PM facility record review of six resident files and four staff records began. The administrator was advised licensing fees are due on 09/03/21.

No deficiencies were observed during today's inspection. Exit interview conducted and report reviewed with the administrator. A copy of the report will be emailed to the administrator.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021
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 3