197608878-3-21-2024-29-AS-DPEA-D3TUWU-20240329155718

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608878
Report Date: 03/21/2024
Date Signed: 03/21/2024 11:30:45 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
09/07/2023 and conducted by Evaluator Martha Arroyo

COMPLAINT CONTROL NUMBER: 29-AS-20230907163503

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:	03/21/2024
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Joeyvic Alvarado		TIME COMPLETED:	11:35 AM

ALLEGATION(S):

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Staff did not adequately care for resident's wound.
Staff did not ensure facility is free of insects.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegations. The initial visit was conducted on 09/08/2023, and a subsequent visit was conducted on 02/29/2024 by LPA M. Arroyo. On today's visit, LPA Arroyo met with Executive Director (ED), Joey Alvarado. Entrance interview.

During the initial visit on 09/08/2023, at 9:40 a.m., LPA Arroyo conducted a tour of the facility to ensure there were no health and safety concerns, toured the kitchen/dining room/food area at 9:43 a.m., conducted interviews with the Administrator and two staff between 8:50 a.m. and 9: 45 a.m., conducted a file review at 9:15 a.m., and obtained copies of pertinent documents. On 02/29/2024, LPA Arroyo conducted interviews with one staff, eight residents, and two family members between 1:03 p.m. and 2:05 p.m. and obtained copies of pertinent documents. Hospital records were also requested and reviewed.

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: 03/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024

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-20230907163503

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: 03/21/2024

NARRATIVE

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Continued from LIC 9099...

It was alleged that staff did not adequately care for resident’s wound. It was reported that Resident #1 (R1) had come into the hospital with an open wound that had maggots in it. Information obtained during the course of the investigation revealed that R1 was admitted to the facility on 08/31/2021. Additionally, per R1 Physician’s Report dated 08/20/2021, it indicates R1 is able to follow instructions, able to communicate needs, does not require assistance for activities of daily living (ADL’s), is able to administer their own medications, and is ambulatory. Hospital records reviewed revealed that R1 was admitted to the hospital on 09/06/2023 due to left thigh cellulitis. Per hospital report, maggot infestation in chronic left lower leg wound located on lateral aspect of left shin. Visualized maggot movement while in the emergency room during admission. R1 reported this was a chronic wound that had been there for less than a year and was unaware of any maggot infestation. Additionally, records review of resident notes revealed that R1 had reported to facility staff that they were not feeling well; however, refused to have paramedics be called to the facility and assist. Instead R1 decided to wait for a family member to arrive and take them to the emergency room. Furthermore, R1 did not report cellulitis or wound to facility staff at any time prior to leaving the facility. And although R1 had cellulitis that became infected, R1 was independent while living at the facility and was capable of reporting wound to facility staff so that it could have been properly cared for. Based on the information obtained and reviewed, the Department does not have sufficient evidence to support the allegation of “staff did not adequately care for resident’s wound”. Therefore, it is being deemed Unsubstantiated at this time.

It was alleged that staff did not ensure facility is free of insects. It was reported that a fly must have gotten into the dining area. During the facility walkthrough on 09/08/2023, the LPA observed the dining rooms and food areas in both assisted living and memory care. There were no flying insects or flies observed inside the facility at the time of the visit. Interviews conducted with staff revealed that the back door where all food deliveries are made has a large fan that blows air to keep flying insects out.

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: 03/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230907163503

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: 03/21/2024

NARRATIVE

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Continued from LIC 9099C...

Additionally, inside the kitchen on the walls, there are blue lights that also kill flying bugs if they were to get inside. Interviews conducted with residents revealed that they have not observed flies or insects either in their bedrooms or while at the dining room. Furthermore, records review revealed that facility has been utilizing Western Exterminator Company on a monthly basis with no concerns noted after maintenance treatment. Based on the information obtained and reviewed, the Department does not have sufficient evidence to support the allegation of “staff did not ensure facility is free of insects”. Therefore, it is being deemed Unsubstantiated at this time.

Exit interview. No citations issued. Report was reviewed with the ED and a copy was issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024

LIC9099 (FAS) - (06/04)

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