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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608878
Report Date: 07/14/2023
Date Signed: 07/14/2023 04:26:10 PM

Substantiated


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
11/30/2021 and conducted by Evaluator Kasandra Lopez
COMPLAINT CONTROL NUMBER: 29-AS-20211130112439
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: 96DATE:
07/14/2023
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Michelle GreenbergTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Licensee did not report resident's change of condition to the responsible party timely
Insufficient staffing
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced subsequent complaint inspection at the facility today regarding the above allegations. The LPA met with Business Office Manager Michelle Greenberg and explained the reason for today's visit.

On 12/03/2021, LPA Lopez initiated the investigation and conducted interviews with six residents and five staff between 11:11 AM and 3:09 PM. The LPA also reviewed records and received pertinent copies.

On 02/15/2023, the LPA conducted a subsequent inspection and interviewed one facility staff and three residents pertaining to the investigation between 10:44 AM and 3:15 PM.

During today's visit, the LPA interviewed three staff between 12:59 and 1:40 PM and reviewed facility records.

Report continued on LIC 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023
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 5
Control Number 29-AS-20211130112439
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: 07/14/2023
NARRATIVE
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Allegation: Licensee did not report resident's change of condition to the responsible party timely.

The allegation alleges on 11/15/2021, Resident #1's (R1) leg was red and needed medical attention and R1's Responsible Party (RP) was not notified until 11/19/2021. Record review revealed on 11/16/2021, the physician of R1 was faxed notifying them of insect bites on R1’s leg that were getting bigger and requesting advice. On 11/19/2021, the physician responded via fax requesting photos or to schedule a visit. Email correspondences between the RP and facility nurse Staff #2 (S2) revealed on 11/19/2021, S2 emailed RP requesting RP to take R1 to the urgent care due to R1’s physician not responding back to them.

Based on the information obtained, there is sufficient evidence to support R1’s Responsible Party was not notified timely of R1’s change of condition. Therefore, the allegation of licensee did not report resident's change of condition to the responsible party timely is deemed substantiated at this time.

Allegation: Insufficient staffing

The allegation alleges there is only one med tech on staff on shift which is not sufficient. Review of the staff schedule from 11/14/2021 through 12/11/2021 revealed frequently there is only one med tech on the AM and PM shift instead of two med techs for each shift like on the other days. Interviews with four med techs who worked around the time the complaint was filed, revealed having only one med tech on shift in assisted living is not sufficient and as a result medications are being delivered late to the residents. A review of the current staff schedule revealed there is one med tech and one half day med tech during the AM and PM shift. The half day med tech works during peak hours from 6:00 AM-10:00 AM and 4:00 PM – 8:00 PM. Interviews today revealed staff are able to meet the resident’s needs under the current schedule. Based on the information obtained, there is sufficient evidence to support the allegation of insufficient staffing occurred at the time the complaint was filed. Therefore, the allegation is deemed substantiated at this time.

The following deficiencies were cited from the CA Code of Regulations. See LIC 9099-D. Exit interview and report reviewed with Business Office Manager Michelle Greenberg. A copy of the report and appeal rights provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
11/30/2021 and conducted by Evaluator Kasandra Lopez
COMPLAINT CONTROL NUMBER: 29-AS-20211130112439

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: 96DATE:
07/14/2023
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Michelle GreenbergTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff are verbally abusive to residents
INVESTIGATION FINDINGS:
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Allegation: Staff are verbally abusive to residents

The allegation alleges Staff #1 (S1) was verbally abusive to Resident #1 (R1) and would yell at R1 and slammed a door in R1’s face. On 12/03/2021 and on 02/15/2022, the LPA conducted interviews with R1. During the interviews, R1 had no complaints regarding staff or how staff treated them. Record review and interviews revealed R1 has memory impairment. Interviews with residents revealed no issues or concerns regarding how they are treated by staff members. Interviews with staff revealed no observation of S1 yelling at R1 or slamming a door in the face of R1 and only heard rumors of it happening. One staff member recalled R1 coming to the medication room to ask S1 about their medications and when they were done talking, S1 closed the medication room door but stated the resident was not near the door at the time and the door was not slammed. Some staff reported that R1 stated they did not like S1.

Report continued on LIC 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20211130112439
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: 07/14/2023
NARRATIVE
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During the interview with S1, S1 denied ever yelling or being rude to R1 and denied ever slamming a door in R1’s face. Based on the information obtained, there is insufficient evidence to support the allegation of staff are verbally abusive to residents occurred. Therefore, the allegation is deemed unsubstantiated at this time.

Exit interview and report reviewed with Michelle Greenberg. A copy of the report and appeal rights provided.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20211130112439
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: 07/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/21/2023
Section Cited
CCR
87466
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87466 Observation of the Resident
The licensee shall ensure that residents are regularly observed for changes in physical, mental,...such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.

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The Administrator shall submit a plan of correction on how they will ensure the deficiency does not occur again. Plan of correction to be submitted to CCL by 07/21/2023.
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This requirement is not met as evidenced by:
Based on interview and record review, the licensee failed to comply with the section cited above as R1's responsible party was not notified of a change of condition timely which poses a potential health and safety risk to R1 in care.
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Type B
07/21/2023
Section Cited
CCR
87411(a)
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87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
This requirement is not met as evidenced by:
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The Administrator shall submit a plan of correction on how they will ensure the deficiency does not occur again.
Plan of correction to be submitted to CCL by 07/21/2023.
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Based on interviews and record review, the licensee failed to comply with the section cited above as insufficient staffing resulted in residents getting their medications late which poses a potential 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.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5