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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608878
Report Date: 11/10/2021
Date Signed: 11/10/2021 06:11:52 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 HILLSFACILITY NUMBER:
197608878
ADMINISTRATOR:MATAN BURSTYNFACILITY TYPE:
740
ADDRESS:5217 CHESEBRO RDTELEPHONE:
(818) 991-3544
CITY:AGOURA HILLSSTATE: CAZIP CODE:
91301
CAPACITY:185CENSUS: 93DATE:
11/10/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:09 PM
MET WITH:Joeyvic AlvaradoTIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Case Management - Deficiencies inspection at the facility due to a deficiency observed during complaint investigation control number 29-AS-20211102115349. The LPA met with Administrator Joey Alvarado who became the Administrator of the facility as of 11/08/2021.

On 10/21/2021, an incident occurred between Resident #1 (R1) and Resident #2 (R2) where R1 accused R2 of pushing R1. R1 was observed on the ground by staff after the incident occurred and later complained of shoulder pain. On 11/04/2021, the Suspected Dependent Adult/Elder Abuse form (SOC 341) only, was completed by Operations Specialist Walter Cline and faxed to the ombudsman and CCL regarding the 10/21/2021 incident. LPA Lopez discussed the issue of the facility not completing the licensing report and issuing the report timely. An Unusual Incident/Injury Report (LIC 624) was completed today and a copy was given to the LPA.

Based on the information obtained, the licensee failed to submit a written report of the incident to licensing within seven days, therefore a citation is being issued.

Exit interview and report reviewed with Administrator Joey Alvarado. A copy of the report and appeal rights was emailed.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021
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
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: 11/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/12/2021
Section Cited

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87211 Reporting Requirements
(a) (1) (A-D) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below......
This requirement is not met as evidenced by:
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Based on record review and interview, the licensee failed to comply with the section cited above as a written report was not received within 7 days of the 10/21/2021 occurrence which poses a potential health, safety, or personal rights 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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:
DATE: 11/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2021
LIC809 (FAS) - (06/04)
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