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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608878
Report Date: 03/12/2025
Date Signed: 03/12/2025 03:20:45 PM

Document Has Been Signed on 03/12/2025 03:20 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/
DIRECTOR:		JOEYVIC ALVARADOFACILITY TYPE:
740
ADDRESS:5217 CHESEBRO RDTELEPHONE:
(818) 991-3544
CITY:AGOURA HILLSSTATE: CAZIP CODE:
91301
CAPACITY: 185TOTAL ENROLLED CHILDREN: 0CENSUS: 126DATE:
03/12/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:50 PM
MET WITH:Joeyvic AlvaradoTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management Incident inspection at the facility today. The LPA met with Administrator Joeyvic Alvarado and explained the reason for the inspection.

On 02/27/2025, Community Care Licensing (CCL) received an Unusual Incident/Injury Report (LIC 624) pertaining to Resident #1 (R1). Please note report was submitted after hours and LPA did not receive until 02/28/2025. The report stated that on 02/25/2025, while walking on the beach with several residents, R1 lost their balance and fell. R1 was transferred to the hospital for immediate medical treatment. Furthermore, R1 returned to the community on 02/26/2025 with a back fracture.

On 02/28/2025, the LPA spoke with Administrator Joey Alvarado regarding the incident. She stated R1 was out on an outing to the beach with other residents and staff, they were walking the board walk and after the fall R1 was sent to the hospital and was diagnosed with a back fracture. The Administrator stated when Staff 1 (S1) was interviewed they conveyed that they were walking holding R1, and another resident (R2) by hands and when a third resident (R3) walked passed them, R2 let go of S1's hand to follow R3. S1 let go of R1 in an attempt to go after R2 and R1 fell. The Administrator stated R1 uses a walker, however S1 did not take R1's walker to the outing as they felt confident that they were going to be able to hold on to them and S1 received a corrective action.

During today's inspection, the LPA conducted file review for R1 and S1 beginning at 1:28 PM. File review revealed that per R1's Resident Appraisal (LIC603A) dated 09/24/24, R1 has balance issues, ambulatory with assistance, needs assistance in walking, and is not able to walk without any physical assistance (e.g., walker, crutches, other person), or not able to walk with a cane. Per R1's Physician Report (LIC602) dated 09/24/24, R1 has a history of mechanical fall. Furthermore, R1's file review also revealed that R1 uses a walker and is a high fall risk. Report will continue on LIC809-C, 2nd page.
Kasandra LopezTELEPHONE: (818) 596-4343
Esther CortezTELEPHONE: (747) 230-2225
DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 03/12/2025
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File review revealed that on 02/28/2025, S1 received a corrective action notice for allowing residents to get off the bus to walk on the sand during a scenic drive to the beach, and one of those residents was taken off the bus without their assistive device which caused them to fall. Furthermore, S1 received a safety in-service training on 02/28/2025.

Based on the information obtained, there is sufficient evidence to support a deficiency is warranted as R1 sustained an injury as a result of S1 taking R1 on an outing to the beach without their assistive device. The following deficiency was cited (See LIC 809-D) from CA Code of Regulations, Title 22, Division 8. Failure to correct the deficiencies may result in civil penalties. An immediate civil penalty of $500 was issued. Exit interview conducted. A copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/12/2025 03:20 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 03/12/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/12/2025
Section Cited
CCR
87468.1(a)(2)

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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement is not met as evidence by:
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Plan of correction cleared: S1 received a corrective action and safety training regarding the use of assistive device and scheduled programs. An immediate civil penalty of $500 is warranted in accordance with California Health and Safety Code Section 1569.49(c)(1).
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Based on interview and record review, the licensee failed to comply with the section cited above, as R1 sustained a back fracture due to S1 taking R1 on an outing without their assistive device which is an immediate health risk to R1 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.
Kasandra LopezTELEPHONE: (818) 596-4343
Esther CortezTELEPHONE: (747) 230-2225

DATE: 03/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2025

LIC809 (FAS) - (06/04)
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