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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881058
Report Date: 04/12/2023
Date Signed: 04/12/2023 03:04:38 PM


Document Has Been Signed on 04/12/2023 03:04 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: 33DATE:
04/12/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Assistant Administrator Andrea ScottTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the facility 04/12/2023 at 09:45 AM for a Case Management Deficiency visit. During this visit, LPA Brown was met by Assistant Administrator Andrea Scott.

During the visit, LPA Brown was informed two (2) individuals - Person #1 (P1) and Person #2 (P2) resides at Building 3 of the facility with criminal background clearance but not associated to the facility since a month ago. During the the tour of the facility, two individuals reported residing at the facility were not in Building 3 as residents reported that they saw them drive out of the facility before LPA Brown arrived. LPA Brown contacted Licensee/Administrator Ebraheem Hamed and informed Licensee/Administrator Hamed that deficiency will be issued for this issue as this posed immediate Health, Safety and personal rights risks to residents in care. Civil Penalty was assessed for allowing P1 and P2 to reside at the facility without criminal background clearance transfer for P1 and P2 to be associated to the facility with the amount of $500.00 per individual and will continue to be assessed of $100.00 per day per citation until corrected.



In addition, during the tour of the facility, LPA Brown observed two (2) residents' bathroom have mold/mildew in their bath tub/shower. LPA Brown pointed out the mold/mildew observed in two (2) bathrooms in Room #15 and Room #19 to Staff #2 (S2) and Staff #3 (S3) and they both confirmed mold/mildew observed. LPA Brown informed Administrator Scott that the facility will be cited for this issue as this pose potential health, safety and personal rights risk to residents in care.LPA Brown explained to Assistant Administrator Scott that the facility was cited for the same deficiency for mold at the facility last 01/25/2023. Civil Penalty was assessed for repeat violation on Maintenance and Operation within a 12-month period with the amount of $250.00 and will continue to be assessed of $100.00 per day per citation until corrected

***Continuation in LIC809C ***
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/12/2023
NARRATIVE
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An exit interview was conducted where this report LIC809, LIC809D, LIC421BG, LIC421FC and Appeal Rights were discussed and provided to Assistant Administrator Andrea Scott .
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 04/12/2023 03:04 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/20/2023
Section Cited

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87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:(2) Request a transfer of a criminal record clearance... This requirement is not met as evidenced by:
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Licensee stated to transfer P1 and P2 crimibal background clearance to the facility and submit proof to LPA Brown by POC due date.
Licensee stated to submit signed Statement of Understanding on CCR 87355(e)(2) to LPA Brown by POC due date.
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Based on observations, interviews and records review, the Licensee did not comply with the section cited above by not transferring P1 and P2's criminal record clearance to the facility which pose potential health, safety and personal rights risks to residents in care.
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Type B
04/22/2023
Section Cited

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87303 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 is not met as evidenced by:
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Licensee stated that they will remove the mold/mildew in residents bathroom in Room #15 and Room #19 and submit proof to LPA Brown by POC due date.
Licensee will submit signed statement of Understanding on CCR 87303(a) to LPA Brown by POC due date.

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Based on observations, interview and records review, the Licensee did not comply with the section cited above by not ensuring residents bathing areas were clean and sanitary. The bath tub/shower in Room #15 and Room #19 were observed to have mold/mildew which pose potential health, safety and personal rights risks to residens in care.
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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: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2023
LIC809 (FAS) - (06/04)
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