331881058-5-7-2021-18-AS-EMAN-CG9MXT-20220712100024

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331881058
Report Date: 05/07/2021
Date Signed: 05/07/2021 02:56:27 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/30/2021 and conducted by Evaluator Jennifer Semin

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210430095837

FACILITY NAME:	MEADOWBROOK ASSISTED LIVING, LLC		FACILITY NUMBER:	331881058
ADMINISTRATOR:	HAMED, EBRAHEEM		FACILITY TYPE:	740
ADDRESS:	461 E JOHNSTON AVE		TELEPHONE:	(951) 658-8875
CITY:	HEMET	STATE: CA	ZIP CODE:	92543
CAPACITY:	49	CENSUS: 35	DATE:	05/07/2021
		UNANNOUNCED	TIME BEGAN:	09:27 AM
MET WITH:	Ebraheem Hamed		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Centrally stored medicines are not kept in a safe and locked place.
Facility does not ensure that residents have clean linens.
Facility does not ensure that residents have clean clothing.
Facility has an insect infestation.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jennifer Semin conducted an unannounced visit to the facility to initiate a complaint investigation and deliver the findings. LPA met with licensse, Ebraheem Hamed .

The investigation consisted of observations and interviews with relevant parties.
The first allegation indicates that centrally stored medicines are not kept in a safe and locked place. .Staff indicated the medication room is always locked when not in use. LPA observed the medication room to be locked and inaccessible to residents.
The second and third allegations indicate that the facility does not ensure that residents have clean linens and clothing. Interviews with staff and residents indicated the facility provides regular laundry service for clothing and linens. Staff interviewed indicated 2 weeks ago they were taking the laundry to a laundry mat while waiting for the new washers and dryers to be delivered. Staff indicated they had never been asked to take laundry to their private residence to wash it. LPA observed a two working washing machines and

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Jennifer Semin	TELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2021

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 4

Control Number 18-AS-20210430095837

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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, LLC	FACILITY NUMBER: 331881058
	VISIT DATE: 05/07/2021

NARRATIVE

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dryers. Investigation did not reveal further information to either refute or corroborate the allegations.
The forth allegation indicates the facility has an insect infestation. Interviews with staff and residents indicated they have never seen any insects or an insect infestation. LPA did not observe any indication that insects had been or were present. Staff stated they have pest control service monthly. Investigation did not reveal further information to either refute or corroborate the allegation.

Based upon interviews and information gathered, and although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED at this time.

An exit interview was conducted where this report was discussed and provided to Ebraheem Hamed.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Jennifer Semin	TELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/30/2021 and conducted by Evaluator Jennifer Semin

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210430095837

FACILITY NAME:	MEADOWBROOK ASSISTED LIVING, LLC		FACILITY NUMBER:	331881058
ADMINISTRATOR:	HAMED, EBRAHEEM		FACILITY TYPE:	740
ADDRESS:	461 E JOHNSTON AVE		TELEPHONE:	(951) 658-8875
CITY:	HEMET	STATE: CA	ZIP CODE:	92543
CAPACITY:	49	CENSUS: 35	DATE:	05/07/2021
		UNANNOUNCED	TIME BEGAN:	09:27 AM
MET WITH:	Ebraheem Hamed		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Facility is in disrepair.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jennifer Semin conducted an unannounced visit t the facility to initiate a complaint investigation and deliver the findings. LPA met with Ebraheem Hamed.

The allegation indicates that the facility in in disrepair. LPA observed broken windows in building #1 in the dining room, in the living room and in room #9. Building #2 has broken windows in room #19, room #24, and room #26. LPA observed hand rail leading to Building #1 to be rusted out, broken and falling apart. This poses a serious health and safety risk to residents in care.
Based upon observations, interviews conducted, and information gathered, the preponderance of the evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED, California Code of Regulations Title 22 is being cited on the attached LIC 9099D.
An exit interview was conducted where this report was discussed and provided to Ebraheem Hamed .

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Jennifer Semin	TELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2021

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 4

Control Number 18-AS-20210430095837

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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, LLC	FACILITY NUMBER: 331881058
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/07/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/08/2021 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	MAINTENANCE AND OPERATION The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requlation was not met as evidenced by	1 2 3 4 5 6 7	Licensee shall complete repairs to broken windows and hand rail and submit proof to CCL by the POC due date of 5/8/2021.
	8 9 10 11 12 13 14	LPA observed broken windows in building #1 in the dining room, in the living room and in room #9. Building #2 has broken windows in room #19, room #24, and room #26. LPA observed hand rail leading to Building #1 to be rusted out, broken and falling apart. This poses a serious health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Jennifer Semin	TELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 4