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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608878
Report Date: 08/14/2024
Date Signed: 08/14/2024 01:04:46 PM


Document Has Been Signed on 08/14/2024 01:04 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:MEADOWBROOK AT AGOURA HILLSFACILITY NUMBER:
197608878
ADMINISTRATOR:JOEYVIC ALVARADOFACILITY TYPE:
740
ADDRESS:5217 CHESEBRO RDTELEPHONE:
(818) 991-3544
CITY:AGOURA HILLSSTATE: CAZIP CODE:
91301
CAPACITY:185CENSUS: DATE:
08/14/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Shari LefevreTIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analysts (LPA) Sandra Urena, Trevor Byrne and Erica Mosley conducted an unannounced case management-other visit. The LPAs arrived at the facility at 09:55 a.m. The LPAs met with Diane Lugar, Operations Specialist (OS), Shari Lefevre, Regional Director of Operations, and Guadalupe Santos, Memory Care Director, and explained the reason for the visit.

The purpose of the visit is to gather additional information about the death report (LIC 624) for R1, which was submitted to the Community Care Licensing (CCL) department on 08/05/2024. It is unclear as to what caused the death of R1. R1 had a fall (witnessed by staff) on 08/3/2024 at approximately 9:15 p.m., prior to being hospitalized. R1 died at the hospital the following morning after he fall.

The LPAs interviewed Guadalupe Santos, Memory Care Director (MCD) and Diane Lugar from 10:34 a.m. to 10:40 a.m. and requested records pertinent to the case at 10:45 a.m. Per the MCD, they requested the death certificate(DC) from the family members on 08/07/2024; however the family member stated that they not had obtained a DC yet , but as soon as they received a copy they would send it to the facility.

Further investigation is needed at this time.

Exit interview was conducted and a copy of the report was issued.

SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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