331881058-1-6-2023-18-AS-JESL-CQD25U-20230328170608

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331881058
Report Date: 01/06/2023
Date Signed: 01/06/2023 03:05:16 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
01/03/2023 and conducted by Evaluator Chinwe Nwogene

COMPLAINT CONTROL NUMBER: 18-AS-20230103125237

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:	01/06/2023
		UNANNOUNCED	TIME BEGAN:	12:05 PM
MET WITH:	Andrea Scott, Assistant Administrator		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility is in disrepair.
Facility staff do not keep resident''s room clean and free of trash.

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Chinwe Nwogene conducted an unannounced visit to investigate the above allegation(s). LPA met with Assistant Administrator, Andrea Scott who was informed of the purpose of the visit. At the time of visit, LPA interviewed staff, interviewed residents, and conducted an inspection of the facility.
Regrading the allegation “Facility is in disrepair”. It was alleged shared toilet in building #1 between bedroom #6 and bedroom #7 wasn’t properly flushing and resident had to use a hanger to flush the toilet. LPA inspected the toilet and observed residents uses a hanger to flush the toilet and the toilet wasn’t flushing properly. LPA also observed the bathtub in the hallway bathroom to be dirty and rusty. LPA interviewed Assistant Administrator who stated the whole building one #1 is being renovated and the bathrooms will be fixed when the renovation is done.
Regarding the allegation “Facility staff do not keep resident’s room clean and free of trash”. LPA interviewed residents who stated staff do not clean their rooms. LPA interviewed staff who stated residents’ rooms are not cleaned daily. Staff stated residents’ rooms are cleaned if or when residents request for their rooms to be cleaned. LPA conducted inspection of the facility and observed residents’ bedroom #2 in building #1 to be dirty.
Based on LPA’s observations, and interviews the preponderance of evidence standard has been met. Therefore, the above allegation(s) are found to be substantiated. California Code of Regulations (Title 22, Division & Chapter number 6) are being cited on the attached LIC9099D). An exit interview was conducted, and a copy of this report was reviewed and provided along with appeal rights to Andrea Scott.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Chinwe Nwogene	TELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2023

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

Control Number 18-AS-20230103125237

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: 01/06/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/13/2023 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	Maintenance and Operation; 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.	1 2 3 4 5 6 7	Assistant Administrator, Andrea Scott stated a picture of a cleaned bathtub, resident bedroom and fixed toilets will be sent to LPA by POC due date 01/13/2023
	8 9 10 11 12 13 14	This requirement is not met based as evidence by observation, and interview. The licensee did not comply by staff not cleaning residents rooms, toilet not flushing and dirty bathtub which poses a potential health, safety or personal rights risk to persons 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) 248-0313
LICENSING EVALUATOR NAME: Chinwe Nwogene	TELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2023

LIC9099 (FAS) - (06/04)

Page: 2 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
01/03/2023 and conducted by Evaluator Chinwe Nwogene

COMPLAINT CONTROL NUMBER: 18-AS-20230103125237

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:	01/06/2023
		UNANNOUNCED	TIME BEGAN:	12:05 PM
MET WITH:	Andrea Scott, Assistant Administrator		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff do not treat resident(s) with dignity and respect.
Facility staff yell at resident.

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Chinwe Nwogene conducted an unannounced visit to investigate the above allegation(s). LPA met with Assistant Administrator, Andrea Scott who was informed of the purpose of the visit. At the time of visit, LPA interviewed staff, and residents.
Regrading the allegation “Facility staff do not treat resident(s) with dignity and respect”. It was alleged staff was rude to resident and moved resident #1 (R1) from room to room. LPA interviewed staff who denied being rude to resident. LPA interviewed Assistant Administrator who stated resident #1 (R1) was moved to a different bedroom because resident had an altercation with roommate. LPA interviewed residents who denied staff was rude to them.
Regrading the allegation “Facility staff yell at resident”. It was alleged staff yelled at resident when resident requested to speak to facility owner/Licensee. LPA interviewed staff who denied yelling at resident. LPA interviewed residents who denied staff yelled at them.
Based on LPA’s interviews with staff and residents there is not enough evidence to support the above allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of this report was reviewed with and provided to Andrea Scott.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Chinwe Nwogene	TELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2023

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

LIC9099 (FAS) - (06/04)

Page: 3 of 3