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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881058
Report Date: 02/22/2021
Date Signed: 02/22/2021 02:21:05 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:MEADOWBROOK ASSISTED LIVING, LLCFACILITY NUMBER:
331881058
ADMINISTRATOR:HAMED, EBRAHEEMFACILITY TYPE:
740
ADDRESS:461 E JOHNSTON AVETELEPHONE:
(951) 658-8875
CITY:HEMETSTATE: CAZIP CODE:
92543
CAPACITY:49CENSUS: DATE:
02/22/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Ebraheem HamedTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Javier Prieto conducted an announced visit with facility administrator for the purpose for performing a virtual pre-licensing inspection. LPA Prieto met with administrator Ebraheem Hamed. Fire clearance is approved for forty nine (49) non-ambulatory on 12/21/2020. Facility will serve Elderly residents age 59 years and over.

Structure: Facility is a three (3), one story building facility The client bedrooms can accommodate the client's furnishings.
Bathrooms: All bathrooms have a working toilet, shower and sink. Bathrooms have appropriate washing supplies and towels for client use.
Linens: Facility has sufficient linens for clients in care.
Hygiene Supplies: Are kept locked in a storage cabinet within the facility.
Food Service: Kitchen has adequate counter and cupboard space to meet the staff and client’s needs. Pantry is stock. Food is delivered for each meal times from an outside source. Commercial kitchen appliances are in place. Update of such kitchen is in place.
Smoke detectors and Carbon Monoxide Units were tested and are found in working condition.
Toxics Are stored in a locked in locked cleaning supply closet.
Medications Are centrally stored and locked in the facility office, med tech office. First aid kit is kept in med tech room as well as first aid manual. Medication Administrator Records (MAR) logs are kept in med tech room with secured narcotic storage med tech cart. .
Resident & Staff Files; Are centrally stored in facility office.
Overall, the residence meets Title 22 requirements for licensing standards. No corrections are needed at this time. A copy of this report was provided to the administrator. Pre-licensing is a change of ownership, with a recently licensed sister facility. Component III is requested to be waived.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2021
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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