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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608878
Report Date: 12/05/2021
Date Signed: 12/05/2021 04:20:39 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
03/23/2020 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 31-AS-20200323101049
FACILITY NAME:MEADOWBROOK AT AGOURA HILLSFACILITY NUMBER:
197608878
ADMINISTRATOR:TROY BYINGTONFACILITY TYPE:
740
ADDRESS:5217 CHESEBRO RDTELEPHONE:
(818) 991-3544
CITY:AGOURA HILLSSTATE: CAZIP CODE:
91301
CAPACITY:185CENSUS: 88DATE:
12/05/2021
UNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Lauria GallagherTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Medications are not being administered to residents per the doctor's order.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced for a subsequent complaint visit. The LPA met with Community Relations Director Lauria Gallagher and explained the reason for the visit.

During the initial virtual on 09/22/2020, the LPA conducted interviews with staff at 3:59 p.m., 4:00 p.m. and 4:07 p.m. Additional staff interviews took place on 10/02/2020 at 2:53 p.m., on 10/08/2020 at 2:10 p.m., on 10/09/2020 at 9:40 a.m., and on 11/09/2020 at 3:59 p.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. During the 10/04/2021 visit, 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. LPA Desaree Perera interviewed residents' responsible parties on 09/30/2020 at 1:12 p.m. and on 10/05/2020 at 1:44 p.m. and 2:37 p.m.

During today’s visit, the LPA interviewed staff at 12:30 p.m., 12:50 p.m., 1:02 p.m., 1:30 p.m., and interviewed six residents from 1:40 p.m. – 2:10 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: 12/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2021
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 6
Control Number 31-AS-20200323101049
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: 12/05/2021
NARRATIVE
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Regarding the allegation: Medications are not being administered to residents per doctor’s orders

It was alleged that residents were receiving medications outside of the prescribed window; for example, evening medications were administered closer to 10:00 p.m. or 11:00 p.m. To investigate, the LPA interviewed former management personnel whom worked in the Memory Care unit from May 2019 – March 2020. Whereas current staff were unable to corroborate the claims, interviews with former staff revealed that there was an incident in December 2019 where a resident had received medication at around 11:00 p.m. and as a result, a medication technician was fired for the error.

During today’s visit, interviews revealed that on 11/28/2021, there was a medication error in the Memory Care Unit, where approximately twenty-eight (28) residents did not receive their 5:00 p.m. dosage of medication due to an alleged mis-communication. However, the medication logs were signed off, indicating that all residents had been assisted with receiving their medication. Records review demonstrated that the Executive Director reported this incident to LPA Kassandra Lopez on 12/01/2021. Interviews revealed that the residents’ primary care physician had been notified and residents were monitored for any adverse reactions.

Based on the information obtained, there is sufficient evidence to support the claim that medications were not being administered to residents per doctor’s orders. 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: 12/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 31-AS-20200323101049
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: 12/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/07/2021
Section Cited
CCR
87465(a)
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87465(a)(5) Incidental Medical and Dental Care. The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
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The Administrator agreed to do the following:
1. The staff in question was let go, and no longer works at the community.
2. An in-service was held with medication technicians. Sign-in sheet and appropriate documents to be submitted 12/07/2021
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Based on interviews and record review, the licensee did not comply with the section cited above, as residents were not receiving medication timely and recently the residents did not receive evening medications on 11/28/2021, 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: 12/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
03/23/2020 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 31-AS-20200323101049

FACILITY NAME:MEADOWBROOK AT AGOURA HILLSFACILITY NUMBER:
197608878
ADMINISTRATOR:TROY BYINGTONFACILITY TYPE:
740
ADDRESS:5217 CHESEBRO RDTELEPHONE:
(818) 991-3544
CITY:AGOURA HILLSSTATE: CAZIP CODE:
91301
CAPACITY:185CENSUS: 88DATE:
12/05/2021
UNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Lauria GallagherTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff are not meeting the needs of the residents.
Staff do not have proper supplies on hand for resident oxygen.
A manager is not always available for assistance.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced for a subsequent complaint visit. The LPA met with Community Relations Director Lauria Gallagher and explained the reason for the visit.

During the initial virtual on 09/22/2020, the LPA conducted interviews with staff at 3:59 p.m., 4:00 p.m. and 4:07 p.m. Additional staff interviews took place on 10/02/2020 at 2:53 p.m., on 10/08/2020 at 2:10 p.m., on 10/09/2020 at 9:40 a.m., and on 11/09/2020 at 3:59 p.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. During the 10/04/2021 visit, 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. LPA Desaree Perera interviewed residents' responsible parties on 09/30/2020 at 1:12 p.m. and on 10/05/2020 at 1:44 p.m. and 2:37 p.m.

During today’s visit, the LPA interviewed staff at 12:30 p.m., 12:50 p.m., 1:02 p.m., 1:30 p.m., and interviewed six residents from 1:40 p.m. – 2:10 p.m.
Unsubstantiated
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: 12/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 31-AS-20200323101049
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: 12/05/2021
NARRATIVE
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Regarding the allegation: Staff are not meeting the needs of the residents
It was alleged that due to lack of care and supervision, residents were not being repositioned as needed and residents were falling and staff were unavailable to assist. Interviews confirmed that whereas staff do not keep repositioning logs, staff claimed that they reposition residents every two hours. In addition, staff stated that most residents are out of bed and are congregating in common spaces in the memory care unit. Staff claim there are two residents that stay in the room for an extended period of time but are regularly checked on. Additional interviews stated that in general, whereas the community is challenged with insufficient staffing and extended wait times, they still are able to meet the needs of the residents. Regarding falls, staff claim that residents are checked on frequently and regularly assessed if there is an un-witnessed fall. Staff also claim that for all falls, the community calls 911 to ensure there are no internal injuries or bleeding. Lastly, if a resident sustains an un-witnessed fall in their room, as residents are checked every two hours, residents could have fallen within that two-hour time period. Based on the information obtained, there is insufficient evidence to support the claim that staff are not meeting the needs of the residents. This allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Staff do not have proper supplies on hand for resident oxygen.
It was alleged that the facility did not have distilled water for an oxygen tank. Initially, the LPA interviewed former management personnel whom worked in the Memory Care unit from May 2019 – March 2020. Information gathered from interviews were unable to corroborate the claim that supplies were unavailable. Interviews with current staff revealed that there is an assigned lead whom ensures that each resident room is equipped with ample supplies. The LPA toured several resident rooms in the Memory Care Unit and observed that each room had an individual supply of necessary items. Based on the information obtained, there is insufficient evidence to support the claim that staff do not have proper supplies on hand for resident oxygen. This allegation is deemed Unsubstantiated at this time.

Regarding the allegation: A manager is not always available for assistance.


It was alleged that there was ‘rarely’ a manager available to assist as needed. Interviews and records review revealed that the Memory Care Unit had experienced staff turnover as it related to Memory Care Directors. However, staff claimed that for every shift, there was always a manager-on-duty or lead to refer to if there was an immediate need.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 31-AS-20200323101049
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: 12/05/2021
NARRATIVE
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Staff claimed that if the Memory Care unit was without a Director, there was either an assigned point person from the Corporate Office, staff could contact a medication technician, or the manager-on-duty would potentially be in the Assisted Living unit. Staff also shared that if the Memory Care Director was on site, they would sometimes assist with resident care, which could pull them off the floor. Whereas the community could improve the process for communicating the manager-on-duty for collateral agencies or visiting parties, there is insufficient evidence to support the claim that a manager is not always available for assistance. This allegation is deemed Unsubstantiated at this time.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 6