197608878-8-14-2024-29-AS-KLOZ-D9J33Y-20240927175416

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608878
Report Date: 08/14/2024
Date Signed: 08/14/2024 12:59:46 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
08/09/2024 and conducted by Evaluator Sandra Urena

COMPLAINT CONTROL NUMBER: 29-AS-20240809125133

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: 96	DATE:	08/14/2024
		UNANNOUNCED	TIME BEGAN:	09:55 AM
MET WITH:	Shari Lefevre		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Staff are not following a resident's physician's order.

INVESTIGATION FINDINGS:

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Licensing program Analysts (LPAs) Sandra Urena, Trevor Byrne, and Erica Mosley conducted an unannounced 10-day visit to investigate the allegation listed above. The LPAs arrived at the facility at 09:55 a.m. The LPAs met with Diane Lugar, Operations Specialist, Ruth Austin, Divisional Director Health & Wellness, and Shari Lefevre, Regional Director of Operations, and explained the reason for the visit.

The LPAs interviewed Ruth Austin, Divisional Director Health & Wellness, and Shari Lefevre, Regional Director of Operations from 10:11 a.m. to 11: 10 a.m. and requested records pertinent to the allegation at 10:45 a.m. The interviews revealed that the facility does have a policy and prohibits the use of bed rails. Furthermore, the interviews revealed that management became aware that the previous Executive Director did not have residents’ responsible parties sign the bed rail policy; consequently, residents are not aware of the facility’s policy.
Continues on LIC 9099C…

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 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.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20240809125133

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 HILLS	FACILITY NUMBER: 197608878
	VISIT DATE: 08/14/2024

NARRATIVE

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Staff are not following a resident's physician's order.

On the allegation that staff are not following a resident’s physician order; the Reporting Party (RP) stated that on 8/6/2024, a staff removed the bed rails from the resident's (R1) bed because the facility's corporate office stated that bed rails are prohibited at the facility. LPA Urena interviewed the RP on 08/12/2024 from 2:49 p.m. to 3:20 p.m. The RP stated that R1 had a physician’s order for the half bed rails since October 2023; the bed rails were ordered by the physician due to R1 having a history of falling, and R1 is currently receiving hospice care and have a hospice care plan that specifies the need for half bed rails. Furthermore, the RP stated that facility’s corporate office staff made a visit to the facility and ordered bed rails to be removed as of August 6, 2024. The facility’s corporate office staff made the decision to return the bed rails and installed them back on R1’s bed. However, the RP stated that they have witnessed on several occasions that the bedrails are always in the lower position, versus the raised position to prevent R1 from falling out of the bed. R1 stated that they are not aware of the facility’s policy on prohibiting bed rails. The admission agreement signed by the RP does not have the facility’s policy stated on the agreement.

To investigate the allegation, the LPAs reviewed R1’s physician report (LIC 602A), Admission Agreement (LIC 604A), Hospice Plan, physician’s order for bedrails, facility policy on bedrails and/or notification to residents in care about the facility’s bedrail policy. The record review revealed that R1 has a physician’s order for half bed rails dated 12/26/2023. The Admission Agreement (21 pages) does not specify the facility’s policy on bed rails.

Based on the information obtained through interviews and record review; the information revealed that although the half bed rails were removed only temporarily and have been re-installed on R1’s bed, the facility staff failed to inform the R1’s responsible parties of the facility’s policy implementation, and the facility staff failed to follow the resident's physician's order. Therefore, this allegation is deemed Substantiated at this time.

Pursuant to Title 22, California Code of Regulations (CCR), the following deficiency is cited (refer to LIC 9099-D).

Citations were issued. Exit interview was conducted and a copy of the report and Appeal Rights were issued.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20240809125133

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 HILLS	FACILITY NUMBER: 197608878
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/14/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/19/2024 Section Cited CCR 87608(a)(5)(A)	1 2 3 4 5 6 7	87608(a)(5)(A) (a)Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (5)Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator agreed bedrails will beput back on as of 08/14/2024 and provide a 30 day notice abou the bedrail policy to residents responsible parties and submit documentation to CCL by POC due date.
	8 9 10 11 12 13 14	Based on observation and record review, the licensee did not comply with the section cited above as R1’s half bed rails were removed, which poses a potential health and safety risk to persons in care.	8 9 10 11 12 13 14
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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: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024

LIC9099 (FAS) - (06/04)

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