Meadowbrook at Agoura Hills

87625 Managed Incontinence (b)…Requirements for Allowable Health Conditions, the licensee shall be responsible...:(3) Ensuring that incontinent residents are kept clean and dry and that the facility... This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above, as facility staff failed to ensure that R1 was kept clesn and dry, which posed an immediate health and safety risk to residents in care.

Based on record review, the licensee did not comply with the section cited above in one resident who's last LIC602 is dated 11/08/2022 which poses a potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in two cleaning carts that were left unattended with chemicals accessible to the residents in care which posed a potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in three residents rooms that were observed with prescribed medications or over the counter medications and residents could not store their own medications per their LIC602 which poses an immediate health, safety or personal rights risk to persons in care.

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 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.

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.This requirement is not met as evidence by: Based on interview and record review, the licensee failed to comply with the section cited above, as R1 sustained a back fracture due to S1 taking R1 on an outing without their assistive device which is an immediate health risk to R1 in care.

87468.2(a)(4)residents…shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.This requirement is not met as evidence by: Based on interviews, andrecords review, the licensee did not comply with the section cited above as Staff did not respond to residents calls for assistance in a timely manner, which poses a potential health and safety risk to residents in care.

Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility...(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above. Staff did not dispense prescribed medication to three residents during an evacuation which posed an potential health and safety risk to residents in care.

87355(e) All individuals subject to a criminal record review ... shall prior to working, residing ... in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or (2)Request a transfer of a criminal record clearance This requirement is not met as evidence by: Based on interviews and record review, the licensee did not comply with the section cited above. The Operations Specialist/Interim Administrator is not finger printed cleared and associated to the facility, which posed an immediate health and safety risk to residents in care.

87468.2(a)(4)residents…shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.This requirement is not met as evidence by: Based on interviews,records review, and observation the licensee did not comply with the section cited above as Staff did not respond to residents calls for assistance in a timely manner, which poses a potential health and safety risk to residents in care.

Based on observation, the licensee did not comply with the section cited above in two (2) resident rooms where the LPA observed smoke detector not operable or a missing smoke detector which poses an immediate health and safety risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in the kitchen sink of assisted living which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in seven (7) resident rooms where the hot water measured above 120 degrees which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation the licensee did not comply with the section cited above in three resident rooms observed with medications, and per their physicians room they cannot store and administer their medication which poses an immediate health and safety risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in four (4) resident rooms and one unlocked storage room which poses an immediate health and safety risk to persons in care.

87608(a)(5)(A)(a)Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (5)Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. This requirement is not met as evidenced by: Based on observation and record review, the licensee did not comply with the section cited above as R1’s half bed rails were removed, which poses a potential health and safety risk to persons in care.

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet residents’ needs.This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above as interviews revealed there are times when only two caregivers are on duty in the memory care with 28 residents which poses a potential health and safety risk for residents in care.

Based on LPA observation and record review, the licensee did not comply with the section cited above as personal hygiene items were found unlocked and accessible to resident in care inside the memory care unit,which poses an immediate health, safety or personal rights risk to persons in care.

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: 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.

87466 Observation of the ResidentThe 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. 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.

87628(a) Diabetes (a)The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing…and is able to administer his/her own medication…, or has it administered by an appropriately skilled professional. Based on record review, the licensee did not comply with the section cited above. R1 needed assistance with glucose testing and medication administration, which was performed by a med tech and not an appropriately skilled professional, which posed an immediate health risk...

87465 Incidental Medical and Dental Care (g)The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis…. This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above. R1 was not provided timely medical treatment on 02/13/2020 which led to R1’s death, which posed an immediate health and safety risk to residents in care.

87705(c)(6) Care of Persons with Dementia (c)Licensees who... retain residents with dementia...responsible for ensuring the following: (6) Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals. Based on record review, the licensee did not comply with the section cited above.This requirement is not met as evidence by:The licensee failed to develop a care plan to meet R1’s needs and update the care plan when conditions changed, which posed a potential health and safety risk to residents in care.

87705(c)(5) Care of Persons with Dementia (c) Licensees who accept... residents with dementia shall.... ensuring the following: (5)Each resident with dementia shall have medical assessment,.. at least annually…This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above. R1’s condition changed on 7/27/2019 when R1 was moved from AL to the MC Unit. Licensee failed to update R1’s medical assessment, which posed a potential health and safety risk.

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.This requirement is not met as evidence by: Based on interview and record review, the licensee failed to comply with the section cited above, as R1 sustained injury due to S1 using hot water when bathing R1 which is an immediate health risk to R1 in care.

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: 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.

87468.1 Personal Rights of Residents in All Facilities (a) 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 is not met as evidenced by: Based on record review and interviews, the licensee failed to comply with the section cited above, as S1 had multiple reported inappropriate interactions with R1, R2, R3, R4, R5, R6, and R7 which poses an immediate health, safety, and personal rights risk to residents in care.

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: 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.

Based on observation and record review, the licensee did not comply with the section cited above as at least two resident out of 29 in the memory care have Dementia and over the counter medications were being stored in an unlocked memory care unit resident room which poses an immediate health and safety risk to other memory care residents in care.

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: 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.

87211 Reporting Requirements(a) (1) (A-D) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below......This requirement is not met as evidenced by: Based on record review and interview, the licensee failed to comply with the section cited above as a written report was not received within 7 days of the 10/21/2021 occurrence which poses a potential health, safety, or personal rights risk to residents in care.

87411(a) Personnel Requirements – General. 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: Based on interview and records review, the licensee did not comply with the section cited above, as the facility is experiencing staffing challenges, which poses an immediate health and safety risk to residents in care.

87464(f)(1) Basic Services. Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).This requirement is not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited above, as the facility did not ensure that R1’s care needs were met, which is an immediate health and safety risk to residents in care.

87466 Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs.This requirement is not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited above, as the facility staff did not document or report R1’s grooming and hygiene changes to management, R1’s physician, or R1’s representatives, which poses an immediate health and safety risk to residents in care.