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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608878
Report Date: 10/04/2021
Date Signed: 10/04/2021 04:27:01 PM



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
06/09/2020 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20200609154113
FACILITY NAME:MEADOWBROOK AT AGOURA HILLSFACILITY NUMBER:
197608878
ADMINISTRATOR:VANESSA JEWELLFACILITY TYPE:
740
ADDRESS:5217 CHESEBRO RDTELEPHONE:
(818) 991-3544
CITY:AGOURA HILLSSTATE: ZIP CODE:
91301
CAPACITY:185CENSUS: 91DATE:
10/04/2021
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Michelle GreenbergTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Insufficient staffing
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced for a subsequent complaint visit. The LPA met with Michelle Greenberg and explained the reason for the visit.

During the initial visit on 06/11/2020, the LPA interviewed staff at 9:40 a.m., 9:49 a.m., and 10:22 a.m., and conducted a virtual tour of the Memory Care Unit at 10:22 a.m. On 10/02/2020, the LPA interviewed staff at 2:53 p.m. and 3:40 p.m., and on 11/05/2020 at 3:59 p.m. On 9/22/2020, the LPA interviewed representatives from a collateral agency on 09/22/2021 at 10:50 a.m. and 11:37 a.m., and on 9/23/2020 at 9:12 a.m. LPA Desaree Perera interviewed residents' responsible parties on 10/05/2020 at 1:12 p.m., 1:44 p.m. and 2:37 p.m.

Today, the LPA conducted a tour at 9:30 a.m., interviewed staff at 10:15 a.m., 10:37 a.m., 11:45 a.m., 11:57 a.m. and 3:30 p.m., interviewed residents at 11:50 a.m., and 11:55 a.m., and reviewed records at 3:00 p.m.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2021
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 3
Control Number 29-AS-20200609154113
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: 10/04/2021
NARRATIVE
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Regarding the allegation: Insufficient staffing
It is alleged that this facility does not have enough staff. Interviews conducted revealed that out of the thirty-two (32) memory care residents, most of the residents require extensive assistance with care needs (ie. bathing, dressing, incontinent challenges) and at least ten (10) of the residents require a two-person assist for transfers and care. Interviews confirmed that due to lack of staff, staff stated that they regularly transfer residents alone; if staff were to wait for assistance, residents have to wait longer than usual to receive care. Staff claim that they are encouraged to ask for additional assistance for transfers, but chronic under-staffing issues makes this option challenging. Additional interviews with collateral agencies and visitors revealed that individuals have either had to wait an extended period of time or had to locate staff to receive assistance. Whereas it was communicated that there should be three (3) care staff on shift, plus a medication technician, yet there is often only two care staff available to assist with resident care. This facility also relies on agency staff to fill in, yet it was communicated that the staff will often call off. Interviews conducted with management revealed that they are aware that the facility needs additional staffing and is in the process of hiring additional caregivers.

Based on the information obtained, there is sufficient evidence to support the claim that there is insufficient staffing. This allegation is deemed Substantiated at this time.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):


Exit interview conducted, today's reports and appeal rights were reviewed and issued.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20200609154113
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/06/2021
Section Cited
CCR
87411(a)
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87411(a) Personnel Requirements – General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by:
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Licensee has agreed to do the following:
1. Submit a staffing plan, demonstrating how staff numbers will be sufficient to meet the needs of all residents. Plan should also detail how the facility will appropriately assist with residents whom require two staff assistance. Submit Plan by 10/06/2021, end of day
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Based on interview and records review, the licensee did not comply with the section cited above, as the facility is experiencing staffing challenges, which poses an immediate 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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3