331881058-5-23-2022-18-AS-EMAN-CHUPZ7-20220901114502

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331881058
Report Date: 05/23/2022
Date Signed: 05/23/2022 03:16:33 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
04/06/2021 and conducted by Evaluator Jennifer Semin

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210406105815

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: 38	DATE:	05/23/2022
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Ebreheem Hamed		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Facility staff pushed resident.
Facility staff are not administering resident's medications as prescribed.
Facility did not ensure resident had shoes that fit resident.
Facility staff did not meet residents bathing needs.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jennifer Semin conducted an unannounced visit to deliver the findings for the above complaint allegations. LPA met with administrator Ebraheem Hamed.
The investigation consisted of interviews and observations. Regarding the first allegation, Facility staff pushed resident. Relevant Party (RP) stated Resident 1 (R1) told them that they were pushed by facility staff. Staff denied pushing any resident in care including Resident 1 (R1). Resident 2-4 ( R2-R4)stated they have never been pushed or have seen staff push any residents in care. R1 was unable to be interviewed
Regarding the second allegation, Facility staff are not administering resident's medications as prescribed. RP stated R1 told them that staff were not giving R1 their prescribed medication. Interviews with staff revealed staff give all residents their medications as prescribed, but R1 would often refuse to take their medication. R2-R4 reported staff giving them their medication on time and in the correct amount. R1 was unable to be interviewed.
Regarding the third allegation, Facility did not ensure resident had shoes that fit resident. RP stated R1 did not have shoes on that were R1’s size. Interviews with staff revealed staff provided R1 with shoes that

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: 05/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20210406105815

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: 05/23/2022

NARRATIVE

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R1 stated were too small and staff replaced them with a larger size to which R1 stated fit. R2-R4 stated they have always had shoes that fit. R1 was unable to be interviewed.
Regarding the fourth allegation, Facility staff did not meet residents bathing needs. RP stated R1 told RP that facility staff have only bathed R1 twice since January 2021. Staff stated R1 did not move in until March 2021 and that staff did assist R1 with showers until R1 began refusing showers. R2-R4 stated they take showers 3-4 times a week or more if they choose. R1 was unable to be interviewed.

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 Mr. Hamed.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Jennifer Semin	TELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2022

LIC9099 (FAS) - (06/04)

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