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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881058
Report Date: 11/10/2022
Date Signed: 11/10/2022 03:55:54 PM

Unfounded


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
11/07/2022 and conducted by Evaluator Crystal Colvin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20221107164408
FACILITY NAME:MEADOWBROOK ASSISTED LIVING, LLCFACILITY NUMBER:
331881058
ADMINISTRATOR:SHALABI, JAMALFACILITY TYPE:
740
ADDRESS:461 E JOHNSTON AVETELEPHONE:
(951) 658-8875
CITY:HEMETSTATE: CAZIP CODE:
92543
CAPACITY:49CENSUS: 35DATE:
11/10/2022
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Andrea Scott - AdministratorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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9
Facility staff is not allowing resident to receive visitors.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Crystal Colvin arrived unannounced to the facility to conduct an investigation into the allegations listed above. LPA Colvin met with Administrator Andrea Scott and explained the purpose of the visit. Below is a summary of the findings of the complaint:

Regarding the allegation "Facility staff is not allowing resident to receive visitors": LPA Colvin conducted interviews with Reporting Party and facility staff, and reviewed facility resident roster. LPA Colvin determined that the allegation does not pertain to this facility, as LPA Colvin confirmed that the resident does not live at this facility, and instead is a resident at the Skilled Nursing Facility nextdoor with the same name. This agency has investigated the complaint alleging "Facility staff is not allowing resident to receive visitors".
We have found that the complaint was unfounded, meaning that the allegations were false, could not have happened and are without a reasonable basis. We have therefore dismissed the complaint.

An exit interview was conducted with Administrator Andrea Scott and a copy of this report was provided.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2022
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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