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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608878
Report Date: 01/21/2025
Date Signed: 01/21/2025 01:34:28 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
01/13/2025 and conducted by Evaluator Esther Cortez
COMPLAINT CONTROL NUMBER: 29-AS-20250113083252
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: 126DATE:
01/21/2025
UNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH: Joeyvic AlvaradoTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Facility staff are unable to provided medication as prescribed to residents during an evacuation.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Esther Cortez conducted an unannounced subsequent complaint visit for the above allegation. Upon arrival, LPA met with Administrator Joeyvic Alvarado and was explained the reason for the visit. Entrance interview conducted.

On 01/15/2024, between 11:20 a.m. and 4:30 p.m., the LPA conducted a tour of the physical plant, interviewed four (4) staff, thirteen (13) residents, one (1) residents family member, conducted a medication audit for three residents, and collected pertinent documents relevant to the investigation. During today's visit the LPA interviewed four (4) staff, and conducted a file review.

Report will continue on LIC9099-C, 2nd page.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025
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
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
01/13/2025 and conducted by Evaluator Esther Cortez
COMPLAINT CONTROL NUMBER: 29-AS-20250113083252

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: 126DATE:
01/21/2025
UNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH: Joeyvic AlvaradoTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Licensee did not provide the facility with an up to date and readily available emergency disaster plan
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Esther Cortez conducted an unannounced subsequent complaint visit for the above allegation. Upon arrival, LPA met with Administrator Joeyvic Alvarado and was explained the reason for the visit. Entrance interview conducted.

On 01/15/2024, between 11:20 a.m. and 4:30 p.m., the LPA conducted a tour of the physical plant, interviewed four (4) staff, thirteen (13) residents, one (1) residents family member, conducted a medication audit for three residents, and collected pertinent documents relevant to the investigation. During today's visit the LPA interviewed four (4) staff, and conducted a file review.

Report will continue on LIC9099-C, 2nd page.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20250113083252
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: 01/21/2025
NARRATIVE
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On the allegation " Licensee did not provide the facility with an up to date and readily available emergency disaster plan"; it is the concern of the reporting party (RP) that the community had no evacuation plan, and that it was complete chaos during an evacuation. To investigate the allegation the LPA conducted file review and interviews. Information obtained revealed that on 01/09/2025 the community had to evacuate due to the Kenneth Fire. File review revealed that the community has an Emergency and Disaster Plan (LIC610E) on file. A review of the LIC610E indicated that the community had temporary shelter locations, evacuation procedures and staff assignments during an emergency disaster. File review also revealed that the community conducts monthly emergency and fire drills with their last drill conducted on 12/03/2024. Eleven (11) out of thirteen (13) randomly selected residents that were interviewed revealed that they had no concerns regarding the evacuation, it was well handled, they were well taken care of, the staff did the best they could, and that the staff were knowledgeable on the evacuation process. All staff interviewed revealed that the community trained them and has a third-party individual that comes and educates them on what to do during an emergency and/or disaster such as a fire. Additionally, staff interviewed that were present during the evacuation revealed that considering the emergency they were prepared to the best of their ability, the community was getting ready for an evacuation days prior, all residents had evacuation bags ready to go, and they ensured the safety of the residents. Based on the information gathered, the above allegation is deemed unsubstantiated at this time.

Exit interview conducted and report issued.

SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20250113083252
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: 01/21/2025
NARRATIVE
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On the allegation, “Facility staff are unable to provide medication as prescribed to residents during an evacuation”; it is the concern of the reporting party (RP) that residents had no medication or care during an evacuation. To investigate the allegation the LPA conducted interviews and a medication audit for three residents. Information obtained revealed that on 01/09/2025 the community had to evacuate to three relocation sites and several residents left with family members due to the Kenneth Fire. Staff interviewed revealed that medications and incontinence supplies were relocated to the relocation sites, and/or provided to family members that took residents home with them. Eleven (11) out of thirteen (13) randomly selected residents that were interviewed revealed that they had no concerns regarding the evacuation, it was well handled, they were well taken care of, the staff did the best they could, and medications were provided. However, two (2) out of thirteen (13) residents revealed that they were not provided medications during the evacuation. On 01/15/2024, the LPA conducted a medication audit for three residents and observed the following; Resident 1 (R1) had their evening medications, Eliquis 2.5 MG and Potassium CL ER 20MEQ , still in the bubble pack for 01/09/2025 and 01/10/2025. Resident 2 (R2) had their evening medication, Xarelto 20MG medication still in the bubble packs for 01/09/2025 and 01/10/2025. Additionally, based on a pill count for Resident 3 (R3) conducted by the Memory Care Director, the LPA observed that R3 was not provided their morning Letrozole .25MG medication on 1/10/2025. R1 and R2 were evacuated to one of the relocation sites, and R3 went home with family. An interview conducted with R3’s family member revealed that they were not given R3’s medications during the evacuation. Based on the information gathered through interviews, and medication audit, the allegation above 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).
Exit interview was conducted and a copy of the report and Appeal Rights were issued.
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20250113083252
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: 01/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/03/2025
Section Cited
CCR
87465(a)(4)
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Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility...(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
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Licensee will schedule medication training for all med-techs that includes medication distribution during an evacuation and submit proof to CCLD no later than POC due date.
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Based on interviews and records review, the licensee did not comply with the section cited above. Staff did not dispense prescribed medication to three residents during an evacuation which posed an potential health and safety risk to residents in care.
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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 LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5