331881058-11-10-2022-18-AS-JESL-CNL9SU-20230130223806

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331881058
Report Date: 11/10/2022
Date Signed: 11/10/2022 03:57:17 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-20221107205130

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:	11/10/2022
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Andrea Scott - Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility heater inoperable

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 "Facility heater inoperable": LPA Colvin conducted interviews with staff and residents regarding the allegation of the complaint, as well as toured the facility. LPA Colvin observed that one of the two heaters in building #1 is not in use, and has a red warning tag on the system from SoCal Gas stating "Do not use.....it has been left off due to a hazardous condition. For your safety, have a professional make repairs before use". The warning additionally provides a contact number and references that a technician left a notice regarding the heater. LPA Colvin additionally observed that the thermostat connected to the heater showed the current tempurature in that side of building #1 to be 68 degrees. LPA Colvin went to the other side of the building where the functional heater was, and obsereved that thermostat to be reading at 75 degrees.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (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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Control Number 18-AS-20221107205130

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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LPA Colvin interviewed staff and residents and was informed that the heater has not been working since before the cold weather came (reportedly last week) and that there has been no solution provided by the Licensee to ensure residents on the side of the building with the inoperable heater are kept warm. LPA Colvin was informed during interviews that residents are freezing at night, and that the new owner of the facility (change of ownership has not been completed and therefore, they are not the Licensee) promised to bring space heaters for all of the resident rooms today, but that they have not arrived yet to do so. Due to observations and interviews conducted, the allegation "facility heater inoperable" 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 observations made by LPA Colvin, the facility was cited and deficiencies noted on LIC 9099 D. The facility was cited for the same deficiency on 5/18/22, and therefore LPA Colvin will be issuing civil penalties in the amount of $250 for a repeated deficiency. An exit interview was conducted where this report and appeal rights were discussed. A copy this report, LIC 9099D, LIC421FC, and appeal rights were provided to Administrator Andrea Scott during the exit interview.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (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)

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Control Number 18-AS-20221107205130

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 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 by:	1 2 3 4 5 6 7	Licensee agrees to ensure residents are provided with means to be warm and comfortable by Plan of Correction date of 11/11/22. This may be either having the heater fixed by then or providing alternative means of warmth (such as personal heaters). If Licensee chooses second option, the Licensee must still
	8 9 10 11 12 13 14	Based on observations and interviews, the Licensee did not comply with the above regulation with one area of the facility. LPA Colvin observed 1 of 2 heaters in building #1 to be inoperable, as determined by SoCal Gas. This heater heats one half of building. This is an immediate personal rights risk to residents.	8 9 10 11 12 13 14	have the heater for the building fixed (by no later than 30 days). Licensee to provide LPA Colvin with proof of immediate warmth solution for residents by 11/11/22, and proof of fixed heater by 12/10/22.
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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 Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (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)

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