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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 03:58:43 PM

Substantiated


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-20221107155425
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:
12:00 PM
MET WITH:Andrea Scott - AdministratorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff failed to assist resident with medical needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced in order to initiate an investigation of a complaint with the above allegation(s). LPA identified herself and discussed the purpose of the visit and the elements of the allegation(s) with Administrator Andrea Scott. Below is a summary of the findings of this complaint:

Regarding allegation "Staff failed to assist resident with medical needs": LPA Colvin conducted interviews regarding the allegation, which is specific to resident (R1) being prescribed a medication to treat their ithcing bumps on their skin (possibly bug bites or allergies) and facility staff not assisting with obtaining the prescribed medication. LPA Colvin was provided with conflicting stories through interviews regarding what exactly was said by Administrator to R1, however, all interviews agreed that R1 was recently prescribed a medication for this issue, and Administrator directed R1 to contact their doctor due to insurance not covering the medication. LPA Colvin spoke with Administrator at length regarding how the facility manages residents' medical/dental care and ensure that their needs for this are being met.
Substantiated
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)
Page: 1 of 5
Control Number 18-AS-20221107155425
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: 11/10/2022
NARRATIVE
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The Administrator informed LPA Colvin that residents who see the doctors through MedShop, who come to the facility, have the facility staff overseeing their medical information and are kept up to date on what is going on with the resident and what they need. The Administrator stated that residents who use other providers, such as Kaiser or other medical providers, the facility is not involved with their appointments or anything, and that the resident will bring the Administrator information and medication. LPA Colvin noted that by the Administrator telling the resident to contact their doctor and not providing any additional assistance or following up with the resident or doctor to ensure that the issue was resolved and the resident has whatever medication (or substitute) they need (prescribed on 10/25/22 and still not resolved), that the facility is failing to provide the basic care and supervision that is required by all licensed facilities. Therefore, based on interviews conducted, the allegation "Staff failed to assist resident with medical needs" is SUBSTANTIATED.

A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met.

Due to the number of recent complaints which have been filed against the facility, as well as reports of change of ownership, the Department is requesting an Informal Meeting with the current Licensee and the new "owner" of the facility. LPA Colvin will reach out to all parties to provide a date and time for the informal meeting.

Due to observations made by LPA Colvin, the facility was cited and deficiencies noted on LIC 9099 D. An exit interview was conducted where this report and appeal rights were discussed. A copy this report, LIC 9099D, and appeal rights were provided to ______ during the exit interview.
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
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 18-AS-20221107155425
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: 11/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/11/2022
Section Cited
CCR
87465(a)(1)
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Incidental Medical and Dental Care : (a) A plan...shall be developed...and provide for assistance in obtaining such care, by ...: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This was not met by:
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Licensee agrees to assist R1 with contacting doctor and/or pharmacy in order to obtain medication or substitute to aide R1 in treatment of ithcy bumps on skin. Licensee to provided LPA Colvin with update on what the conclusion was after speaking with pharmacy or doctor. Update due to LPA Colvin by 11/11/22.
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Based on interviews, the Licensee did not comply with the above regulation with at least one resident (R1). On 10/25/22 R1 was prescribed a medication for which R1 has failed to receive. Administrator has not provided any assistance or coordination with physician or pharmacy. This is immediate personal rights violation of R1.
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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: 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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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-20221107155425

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:
12:00 PM
MET WITH:Andrea Scott - AdministratorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff does not ensure that facility is free from bugs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced in order to initiate an investigation of a complaint with the above allegation(s). LPA identified herself and discussed the purpose of the visit and the elements of the allegation(s) with Administrator Andrea Scott. Below is a summary of the findings of this complaint:

Regarding allegation "Staff does not ensure that facility is free from bugs": LPA Colvin conducted interviews related to the allegation as well as observed evidence presented at inspection, including discharge paperwork from the hospital. LPA Colvin observed that hospital discharge paperwork lists resident (R1) to have hives due to an allergic reaction. Evidence provided to LPA Colvin included photos of R1's bumps as well as a plastice bag full of black specs. LPA Colvin was unable to determine if black specks were in fact bugs or if they were lint or other debris. LPA Colvin interviewed 1/3 of residents at facility, and the majority of the residents interviewed denied any issue with bugs at the facility. Therefore, due to lack of concrete evidence to support the allegation, the allegation "Staff does not ensure that facility is free from bugs" is UNSUBSTANTIATED.
Unsubstantiated
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)
Page: 4 of 5
Control Number 18-AS-20221107155425
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: 11/10/2022
NARRATIVE
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A finding of UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted with Administrator Andrea Scott and a copy of this report was provided.
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
LIC9099 (FAS) - (06/04)
Page: 5 of 5