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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881058
Report Date: 02/07/2023
Date Signed: 02/07/2023 01:24:40 PM


Document Has Been Signed on 02/07/2023 01:24 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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, LLCFACILITY NUMBER:
331881058
ADMINISTRATOR:SHALABI, JAMALFACILITY TYPE:
740
ADDRESS:461 E JOHNSTON AVETELEPHONE:
(951) 658-8875
CITY:HEMETSTATE: CAZIP CODE:
92543
CAPACITY:49CENSUS: DATE:
02/07/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Ebraheem Hamed & Eileen MartinezTIME COMPLETED:
01:30 PM
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An Informal Meeting was conducted today via Zoom to discuss recent concerns and facility's operation. Persons present at today’s meeting were: Licensing Program Manager (LPM) Joel Esquivel, Licensing Program Analyst (LPA) Crystal Colvin, Licensee Ebraheem Hamed, and Applicant Eileen Martinez. Below are the topics that were addressed during the Informal Meeting tele-visit:
  • Recent Complaints/Deficiencies (Not yet cleared)
  • 11/10/22 – Heater inoperable
  • 11/10/22 – Resident not assisted with obtaining medication

  • Change of Ownership
  • Current Licensee’s involvement
  • Applicant's association to the facility



During this meeting it was reported to Licensing that the Applicant will be ready to move forward with the Application's Unit by February 27, 2023.

An exit interview was conducted and a copy of this report was provided via email to Licensee Ebraheem Hamed for signature.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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