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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881058
Report Date: 04/24/2023
Date Signed: 04/27/2023 10:07:12 AM


Document Has Been Signed on 04/27/2023 10:07 AM - 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:
04/24/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Assistant Administrator Andrea ScottTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Javina George conducted an unannounced case management deficiency visit in response to complaint control number 18-AS-20230411145240. LPA met with assistant administrator Andrea Scott, and explained the purpose of the visit. Pending licensee Eileen Martinez was available via telephone. The facility is in the process of a change in ownership.

On April 4, 2023 the facility relocated Resident #1 (R1). During LPAs complaint visit conducted on April 13, 2023, LPA was informed by the pending Licensee Eileen Martinez. Ms. Martinez stated that R1 was relocated to a skilled nursing facility (SNF) in Tarzana, CA.

An Investigation revealed that R1 was not relocated to a SNF and was moved to the facility's, sister facility Grace Family Homes #197609733, which is also licensed by the department. Grace Family Homes does not have a skilled Nursing side. In addition the department does not license SNF. A deficiency is being cited for Ms. Martinez providing false statements/claims to the department.

An exit interview was conducted, and a copy of this report 809D, and appeal rights were provided to Assistant Administrator Andrea Scott.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2023
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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Document Has Been Signed on 04/27/2023 10:07 AM - 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: 04/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/08/2023
Section Cited

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87207 False Claims
No licness, officer or employeenof a license shall make or dissemenate any false or misleading statement regrding the facility or any of the serives provided by the facility. This requirement is not met as evidenced by:
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The licensee agrees to make a personal statement of understanding about the importance of providing true and accurate information to thed department, The statement is to include the potential risks and consquences of providing misleading/false cliams, or statements.
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1 out of times the licensee stated that R1 was relocated to a skilled nursing facility when in fact the facility is an assisted living. This poses a potential heath, safety, and personal rights risk to persons in care.
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Proof is to be submitted to the department by 5pm on the due date indicated.

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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: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2023
LIC809 (FAS) - (06/04)
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