331881058-1-25-2023-18-AS-DMUN-CNGV6M-20230127150947

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331881058
Report Date: 01/25/2023
Date Signed: 01/25/2023 09:22:07 AM

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
10/07/2022 and conducted by Evaluator Tricia Danielson

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20221007173137

FACILITY NAME:	MEADOWBROOK ASSISTED LIVING, LLC		FACILITY NUMBER:	331881058
ADMINISTRATOR:	SHALABI, JAMAL		FACILITY TYPE:	740
ADDRESS:	461 E JOHNSTON AVE		TELEPHONE:	(951) 658-8875
CITY:	HEMET	STATE: CA	ZIP CODE:	92543
CAPACITY:	49	CENSUS: 35	DATE:	01/25/2023
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Andrea Scott - Administrator		TIME COMPLETED:	09:30 AM

ALLEGATION(S):

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8
9

Residents are not fed healthy meals
Staff smoking in non-smoking area of facility

INVESTIGATION FINDINGS:

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Licensing Program Analyst(LPA) Tricia Danielson arrived unannounced to the facility to conclude an investigation into the allegations listed above. LPA met with Andrea Scott, Administrator and explained the purpose of the visit.
Regarding the allegation "Residents are not fed healthy meals", LPA interviewed eleven witnesses consisting of nine(9) residents and two(2) staff, and made observations. Two(2) of nine(9) residents interviewed reported the meals provided by the facility are not healthy. One(1) of nine(9) residents interviewed complained about the type of food served. One(1) of two(2) staff interviewed acknowledged an improvement in the menu was needed and that the facility had already begun implementing changes. This was confirmed by two(2) of nine(9) residents interviewed. Regarding the allegation "Staff smoking in non-smoking area of facility", it was alleged that staff's smoke was affecting non-smoking residents at the facility. Nine(9) of nine(9) residents interviewed indicated they had never observed staff smoking in non-smoking areas or that they had never observed staff smoking at all. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted and a copy of this report was provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023

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 3

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
10/07/2022 and conducted by Evaluator Tricia Danielson

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20221007173137

FACILITY NAME:	MEADOWBROOK ASSISTED LIVING, LLC		FACILITY NUMBER:	331881058
ADMINISTRATOR:	SHALABI, JAMAL		FACILITY TYPE:	740
ADDRESS:	461 E JOHNSTON AVE		TELEPHONE:	(951) 658-8875
CITY:	HEMET	STATE: CA	ZIP CODE:	92543
CAPACITY:	49	CENSUS: 35	DATE:	01/25/2023
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Andrea Scott, Administrator		TIME COMPLETED:	09:30 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility has mold

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst(LPA) Tricia Danielson arrived unannounced to the facility to conclude an investigation into the allegations listed above. LPA met with Andrea Scott, Administrator and explained the purpose of the visit.
Regarding the allegation "Faclity has mold", it was alleged that room #22 had mold. LPA interviewed eleven witnesses consisting of nine(9) residents and one(1) staff, and made observations. One(1) of nine(9) residents interviewed reported observing mold in their bathtub and added that the facility does not have housekeeping services. Interview with one(1) staff revealed the facility does not have a full time housekeeper and housekeeping is done sporatically by part time staff who are only called in occasionally. During tour of the facility, LPA observed mold and mildew in the bathtub/shower of room #22 as alleged. LPA did not observe mold in any resident bedrooms. Based on LPA’s observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099 D. An exit interview was conducted and a copy of this report was provided along with Appeal Rights.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023

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

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 18-AS-20221007173137

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: 01/25/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/08/2023 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	Maintenance and Operation- (a) 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 requirement was not met as evidenced by:	1 2 3 4 5 6 7	Facility stated housekeeping will work to remove the mold/mildew in room #22 and will conduct a training with all staff and residents to remind them to open windows during bathing times to help eliminate steam build up. Proof of training to be provided to CCL by 2/8/2023.
	8 9 10 11 12 13 14	The facility did not ensure resident bathing areas were maintained with cleanliness. Based on LPA observations, the bathtub/shower in room #22 was observed to have mold/mildew. This poses a potential health, safety, and personal rights risks 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: Deborah Mullen	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023

LIC9099 (FAS) - (06/04)

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