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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608878
Report Date: 08/05/2026
Date Signed: 08/05/2026 03:37:21 PM

Document Has Been Signed on 08/05/2026 03:37 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:		STEPHANIE R. FUNDERBURGFACILITY TYPE:
740
ADDRESS:5217 CHESEBRO RDTELEPHONE:
(818) 991-3544
CITY:AGOURA HILLSSTATE: CAZIP CODE:
91301
CAPACITY: 185CENSUS: 146DATE:
08/05/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Stephanie FunderburgTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Angela Barutyan conducted an unannounced Case Management - Incident visit at 01:15 PM. The purpose of this visit is to conduct an investigation regarding self-reported incidents that occurred on 07/24/2026 and 07/25/2026. LPA met with Executive Director (ED) Stephanie Funderburg and explained the reason for the visit.

During today’s visit, LPA conducted a physical plant tour to ensure there are no immediate health and safety hazards, interviewed three (3) staff members, and reviewed and obtained copies of pertinent documents.

On 07/31/2026, the Department received an incident report stating that on 07/24/2026, Staff #1 (S1) observed smoke emitting from unit #102’s bathroom exhaust fan. The resident was not in their room at the time of the incident. S1 followed fire safety protocols by notifying the Memory Care Director, while Staff #2 (S2) retrieved a fire extinguisher and extinguished the fire. The ED was contacted immediately for assistance. Prior to the to the arrival of the fire department, staff entered the unit to confirm that the fire had been fully extinguished. Circuit breakers were turned off, and the sliding door and windows were opened to ventilate smoke and extinguisher residue from the room. The fire department arrived shortly after and confirmed that power to the unit had already been shut off, noting that the breaker had tripped automatically during the incident. Fire personnel inspected the wiring connected to the bathroom exhaust fan and confirmed there was no damage to the ceiling or electrical wiring. A precautionary walk-through of the property was also completed before departure. Following the incident the facility contacted Cintas, a fire protection service provider, to investigate why the fire alarm system did not activate.

Report Continued on LIC809-C.

Kristin Heffernan
Angela Barutyan
DATE: 08/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
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: 08/05/2026
NARRATIVE
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During today’s visit, LPA toured the Memory Care unit. LPA observed residents in common areas with staff supervision. The Memory Care unit has three (3) delayed egress doors which have a delay set to thirty (30) seconds. Delayed egress door was tested at 02:10 PM and functioned properly. LPA observed power in the Memory Care unit and no immediate health and safety concerns were noted. LPA reviewed proof of backup batteries purchased on 08/05/2026 for the delayed egress doors. Staff stated that during an outage, the delayed egress batteries power the community, resulting in their batteries draining and the delayed egress to be nonfunctional. Staff indicated that the backup batteries will prevent the batteries in the delayed egress doors from emptying during an outage. LPA reviewed documentation of the one-hour in-service training completed on 07/27/2026 for the topic “What to do if delay egress door are not operable / Elopement procedures” conducted with all staff. LPA reviewed a Temporary Service Plan for R1 signed by staff and dated 07/28/2026 to reflect “elopement risk” and “increase supervision with wandering and location engage resident to activities.” Furthermore, R1’s care plan was updated on 07/31/2026 to include “wandering” and “exit seeking” as needing occasional support.

The following deficiency was observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Administrator was informed that failure to correct the deficiency may result in civil penalties.



An additional report may follow if warranted.

Exit interview conducted. Appeal rights and a copy of the report were provided.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Angela Barutyan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/05/2026 03:37 PM - It Cannot Be Edited


Created By: Angela Barutyan On 08/05/2026 at 03:15 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: MEADOWBROOK AT AGOURA HILLS
FACILITY NUMBER: 197608878

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/12/2026
Section Cited
HSC
1569.312(a)

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1569.312 Basic services requirements
Every facility required to be licensed under this chapter shall provide at least the following basic services:
(a) Care and supervision as defined in Section 1569.2. This requirement is not met as evidenced by:
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Following the incident, R1’s primary care provider and responsible party were notified, R1 was reassessed and their Service Plan was updated, and staff received an in-service training on elopement prevention protocols and procedures for managing delayed egress door malfunctions. POC is cleared.
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Based on interview and record review, the licensee did not comply with the section cited above as R1 eloped from the facility while under the care of staff and was found by law enforcement away from the facility approximately 49 minutes later which poses a potential safety risk to clients 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.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Angela Barutyan
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2026


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: 08/05/2026
NARRATIVE
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On 7/25/2026 at 6 AM, a Cintas technician arrived on site to inspect and test the fire alarm system. The functional testing of smoke detectors was performed. The standalone smoke detector inside unit 102 was tested and functioned properly. The technician determined there was insufficient smoke or heat within the unit to trigger the in-room detector during the incident. The hallway smoke detector outside unit 102 was tested and successfully activated the building- wide alarm system, including audible alarms and safety mechanisms.

During today’s visit, LPA observed unit 102. The bathroom exhaust fan in the unit had no visible signs of smoke or fire debris/damage. Staff indicated that the exhaust fan was replaced after the incident and that monthly cleanings of bathroom unit exhaust fans will be conducted. LPA observed three (3) other resident rooms in the Memory Care unit and bathroom exhaust fans appeared clean. LPA observed fire extinguishers throughout the Memory Care unit which were fully charged and last serviced on 05/05/2026. LPA reviewed documentation confirming the service call to Cintas on 07/25/2026. The technician tested the smoke detector inside the unit, the main hallway smoke detector, and checked the smoke detector connections to the fire panel and central station. Smoke detectors “activat[ed] audibles and alarms properly. Fire system was normal when departing from the facility.” No immediate health and safety hazards were noted.

On 07/31/2026, the facility also notified the Department that on 07/25/2026, Resident #1 (R1) had eloped from the Memory Care unit following a power outage. Around 7:38 AM, the community experienced a power outage and power was restored at 7:57 AM. The delayed egress doors in the Memory Care unit did not return to normal operation after power was restored. Director of Plant Operations immediately contacted emergency service provider to troubleshoot the issue. Around 7:54 AM, the ED instructed the staff to ensure the doors were secured until the system was working. Around 9:52 AM, staff discovered that R1 was missing and had last been seen approximately 10 minutes prior, around 09:42 AM. Staff immediately initiated a search of the community including all surrounding areas. At 10:15 AM, R1’s responsible party was notified and local law enforcement was contacted to report R1 missing. At 10:31 AM, approximately forty-nine (49) minutes after R1 was presumed missing, local police located R1 down the street from the community and safely returned R1 to the facility. R1 was evaluated by paramedics and found to be stable with no apparent injuries. Following the incident, R1’s primary care provider was notified, R1 was reassessed and their Service Plan was updated, and staff received an in-service training on elopement prevention protocols and procedures for managing delayed egress door malfunctions.

Report Continued on LIC809-C.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Angela Barutyan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2026
LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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