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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608878
Report Date: 04/09/2025
Date Signed: 04/09/2025 05:58:27 PM

Document Has Been Signed on 04/09/2025 05:58 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:MEADOWBROOK AT AGOURA HILLSFACILITY NUMBER:
197608878
ADMINISTRATOR/
DIRECTOR:		JOEYVIC ALVARADOFACILITY TYPE:
740
ADDRESS:5217 CHESEBRO RDTELEPHONE:
(818) 991-3544
CITY:AGOURA HILLSSTATE: CAZIP CODE:
91301
CAPACITY: 185CENSUS: 135DATE:
04/09/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:50 AM
MET WITH:Joeyvic Alvarado TIME VISIT/
INSPECTION COMPLETED:
06:00 PM
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Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management Incident inspection at the facility today. The LPA met with Administrator Joeyvic Alvarado and explained the reason for the inspection.

On 03/21/2025, Community Care Licensing (CCL) received two (2) Unusual Incident/Injury Report (LIC 624) and two Self-Reports of Suspected Dependant Adult/Elder Abuse (SOC341) pertaining to Resident #1 (R1), Resident #2 (R2), Staff #1 (S1) and Staff #2 (S2). The first Incident report and SOC341 reported that on 03/20/2025, R1 was sitting on their chair by the window with their table in front of them, on their table there was a tray with their dog's food in a bowl with paw prints and R1's food in a container from the communities kitchen. S1 and S2 were with R1. R1 pointed at their dog's bowl and told S1 to warm up their food. R1 has poor vision. S1 warmed up the dog bowl, meanwhile S2 turned around as they did not want to see R1 eat the dog food and S1 gave it to the resident. R1 spat out the food and said "this is nasty, it's my dog's food." S1 took the food away and warmed up the correct food and gave it to the resident. S2 reported the incident to management. The second incident report stated that 03/20/24, S2 observed S1 be rough with R2 as S1 was assisting R2 in moving their legs to bed. It was further reported that the Administrator spoke with R2, who denied any staff had been rough with them.

On 03/21/25, LPA Cortez spoke with the Administrator on the phone. The Administrator stated that S1 was suspended, S2 will receive training on intervention, incidents were reported to ombudsman, resident, residents family, residents physician and Licensing. All the appropriate actions were taken.

Report will continue on LIC809-C, 2nd page.
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Esther Cortez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/09/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: MEADOWBROOK AT AGOURA HILLS
FACILITY NUMBER: 197608878
VISIT DATE: 04/09/2025
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During today's visit the LPA conducted a file review and conducted interviews with R1, R2, S1 and the Administrator. Interviews with R1 confirmed that they had been given dog food, that the staff was careless and the incident made them feel diminished. Interviews with R2 revealed that they have no concerns with the care being provided and they denied staff being rough with them. Phone interview with S1 revealed that S1 did not know that the food in the bowl was dog food, gave R1 the dog food in error as they were was just doing what R1 was asking them to do, even though S2 at one point mentioned it did not look like human food. Furthermore, S1 denied being rough with R2 or any of the residents. File review revealed that S1 had previously been given a corrective action notice for neglect/ not providing appropriate care to residents prior to this incident. The LPA was not able to interview S2. Lastly, interview with the Administrator revealed that as of 03/31/25, R1 no longer works at the community and that all staff were trained on reporting abuse.

Pursuant to Title 22, California Code of Regulations (CCR), the following deficiency is cited (refer to LIC 9099-D).Civil penalty was issued. Exit interview was conducted and a copy of the report and Appeal Rights were issued.
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Esther Cortez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/09/2025 05:58 PM - It Cannot Be Edited


Created By: Esther Cortez On 04/09/2025 at 04:55 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: 04/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/11/2025
Section Cited
CCR
87468.1(a)(1)

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Personal Rights of Residents in All Facilities: Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidence by
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S1 is no longer working at the facility. Administrator agrees to develop a plan on how they will ensure residents are treated with dignity.
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Based on self-reported incident reports the licensee did not comply with the section cited above when a resident was given dog food they were not treated with dignity, which posed a pontential 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.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Esther Cortez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2025


LIC809 (FAS) - (06/04)
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