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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608878
Report Date: 09/21/2022
Date Signed: 09/21/2022 07:48:40 PM

Document Has Been Signed on 09/21/2022 07:48 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:MEADOWBROOK AT AGOURA HILLSFACILITY NUMBER:
197608878
ADMINISTRATOR:JOEYVIC ALVARADOFACILITY TYPE:
740
ADDRESS:5217 CHESEBRO RDTELEPHONE:
(818) 991-3544
CITY:AGOURA HILLSSTATE: CAZIP CODE:
91301
CAPACITY: 185CENSUS: 87DATE:
09/21/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:27 PM
MET WITH:Joey AlvaradoTIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Case Management - Deficiencies inspection due to deficiencies observed during the investigation for Complaint control #29-AS-20211008085239 which were unrelated to the complaint allegation.

During the investigation, record review and interviews conducted revealed former two Administrators had knowledge of suspected elder abuse pertaining to Staff #1 (S1) and residents in care at the facility, but failed to report to Community Care Licensing Division (CCLD), local law enforcement, and the Long Term Care Ombudsman. S1's employment was terminated in 2021.

Pursuant to the CA Code of Regulations and/or the Health and Safety code the following deficiencies are being cited. See LIC 809-D.

Exit interview and report review with current Administrator Joey Alvarado. A copy of the report and appeal rights were emailed.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2022
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 2
Document Has Been Signed on 09/21/2022 07:48 PM - It Cannot Be Edited


Created By: Kasandra Lopez On 09/21/2022 at 04:04 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: 09/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/21/2022
Section Cited
CCR
87405(d)(2)

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87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7).....(2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement is not met as evidenced by:
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Both Administrators are no longer employed by the licensee. No plan of correction due to this time.
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Based on interviews and record review, two former Administrators had knowledge of suspected abuse and failed to comply with applicable laws, and regulations which poses an immediate health and safety risk to residents in care.
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Type A
10/04/2022
Section Cited
CCR87211(c)

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87211 Reporting Requirements (c) Any suspected physical abuse that does not result in serious bodily injury...shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within 24 hours as required by W&I Code Section 15630(b)(1). This requirement is not met as evidenced by:
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The current administrator shall ensure all staff receive training pertaining to W&I Code Section 15630 and mandated reporting and submit proof to CCL by 10/04/2022.
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Based on interviews and record review, former Administrators Vanessa Jewel and Matan Bursytn had knowledge of suspected abuse pertaining to S1 and residents in care and failed to report to local ombudsman, CCLD and law enforcement 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:Desaree Perera
LICENSING EVALUATOR NAME:Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2022


LIC809 (FAS) - (06/04)
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