197608878-11-22-2021-31-AS-KBUY-C98VW8-20211129154732

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608878
Report Date: 11/22/2021
Date Signed: 11/22/2021 10:45:37 AM

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
09/10/2019 and conducted by Evaluator Martha Guzman-Chavez

COMPLAINT CONTROL NUMBER: 31-AS-20190910153131

FACILITY NAME:	MEADOWBROOK AT AGOURA HILLS		FACILITY NUMBER:	197608878
ADMINISTRATOR:	TROY BYINGTON		FACILITY TYPE:	740
ADDRESS:	5217 CHESEBRO RD		TELEPHONE:	(818) 991-3544
CITY:	AGOURA HILLS	STATE: CA	ZIP CODE:	91301
CAPACITY:	185	CENSUS: 93	DATE:	11/22/2021
		UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Joeyvic Alvarado		TIME COMPLETED:	10:44 AM

ALLEGATION(S):

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Facility staff neglected Resident #1 (R1)
Insufficient staffing

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Martha Guzman Chavez conducted an unannounced subsequent complaint visit to the above facility. The purpose of today’s visit is to conclude an investigation initiated by LPA D. Perera and Y. Avetisyan on 09/17/2020. Upon arrival, LPA met with Administrator, Joeyvic Alvarado and the reason for the visit was explained. Entrance interview conducted.

It was alleged that facility staff neglected Resident #1 (R1). It was further reported that R1 sustained a fall in the dining room due to facility staff neglecting to properly place the dining chairs causing R1 to trip. It was also alleged that facility has insufficient staffing in the dining area, especially during mealtime. During the initial 10-day visit, LPAs Perera and Avetisyan conducted a tour of the physical plant in memory care between 5:07am and 5:30am; in addition, LPAs toured the Assisted Living area between 5:36am - 5:55am. Additionally, interviews were conducted with facility staff including but not limited to administrator, Health & Wellness Director, Memory Care Health and Services Director, caregivers, and med techs throughout the visit.

Continued on LIC 9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-Chavez	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20190910153131

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: 11/22/2021

NARRATIVE

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Continued from LIC 9099...

On 01/22/2020, LPA Perera conducted additional interviews with facility residents between 10:40am to 12:18pm. In addition, LPA conducted a brief file review at 1:35pm and obtained pertinent documentation. On 10/05/2020, LPA Perera conducted interviews with random families of residents. On 10/09/2020, LPA Smith conducted interviews with random facility staff. On 08/19/2021, between 9:15am - 10:35am, LPA Guzman-Chavez conducted interviews with random residents and staff at the facility. On 09/10/2021 and 09/29/2021, LPA Guzman-Chavez conducted additional interviews with facility staff.

Information gathered during the course of the investigation revealed that on 09/06/2019, at approximately 1:30pm, R1 sustained a fail in the dining area. It was revealed that R1 was walking and R1’s cane got stuck on the chair and R1 fell. Interviews conducted further revealed that there is sufficient space between the tables and chairs for residents to walk through. However, sometimes residents try to walk through crowded areas causing tripping hazards. Interviews further revealed that staff are mindful in moving chairs for residents when needed. Based on information gathered, the department does not have sufficient evidence to determine that staff neglected R1 by failing to properly place the dining chairs causing R1 to trip and fall. Therefore, the above allegation “Facility staff neglected Resident #1 (R1)” is deemed unsubstantiated at this time.

Information gathered during the course of the investigation revealed that there were no concerns of insufficient staffing in the dining area. A review of facility time sheets revealed that during the month of September 2019, the facility had between four (4) to six (6) dinning staff during the three shifts (morning, afternoon, and night). Based on information gathered, the department does not have sufficient evidence to determine that the facility does not have sufficient staffing in the dining area. Therefore, the above allegation “insufficient staffing” is deemed unsubstantiated at this time.

Exit interview conducted/ No citations issued/ A copy of report provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-Chavez	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021

LIC9099 (FAS) - (06/04)

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