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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881058
Report Date: 04/25/2023
Date Signed: 04/25/2023 10:57:40 AM

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
06/08/2021 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210608161237
FACILITY NAME:MEADOWBROOK ASSISTED LIVING, LLCFACILITY NUMBER:
331881058
ADMINISTRATOR:HAMED, EBRAHEEMFACILITY TYPE:
740
ADDRESS:461 E JOHNSTON AVETELEPHONE:
(951) 658-8875
CITY:HEMETSTATE: CAZIP CODE:
92543
CAPACITY:49CENSUS: 33DATE:
04/25/2023
ANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Licensee/Administrator Ebraheem HamedTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Facility did not obtain appropriate medical care for resident.
Facility is in disrepair.
INVESTIGATION FINDINGS:
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On 04/25/2023 at 10:00 AM, Licensing Program Analyst (LPA) Melody Brown met with Licensee/Administrator Ebraheem Hamed at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office to deliver the findings of the above allegations. LPA Brown explained the purpose of the requested Office Visit. The investigation consisted of observation, interviews and a review of pertinent documentation.

The investigation was conducted by LPA Melody Brown. The investigation consisted of records review and interviews with relevant parties. The allegation indicates that Facility did not obtain appropriate medical care for resident. LPA Brown obtained evidence to corroborate the allegation above. Staff interviews and records review indicated that the facility failed to obtain appropriate medical care follow-up for Resident #1 (R1) from 01/2021 to 03/2021. R1's medical records review revealed that R1 did not get appropriate medical care follow-up until 03/2021 from a fall occured at the facility last 12/2020.
**Continutaion in LIC9099C ***
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023
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 7
Control Number 18-AS-20210608161237
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: 04/25/2023
NARRATIVE
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During the Office Visit, S1 confirmed to LPA Brown that last 03/2021, S1 did not know R1 needs to obtain appropriate medical care follow-up and S1 indicated to LPA Brown that S1 should have checked and followed-up on all the residents at the facility last 03/2021 to see if there were outstanding injuries or appointments to keep or reschedule. In addition, S1 indicated and confirmed to LPA Brown that a staff that's in-charge of making medical appointment at the facility left and never relayed the information regarding R1's need to obtain appropriate medical care follow-up and the unknown knowledge of R1's condition that needs medical care follow-up that time. LPA Brown informed Licensee/Administrator Hamed that deficiency will be issued as this pose immediate health, safety and personal rights risks to residents in care.

The second allegation indicates Facility is in disrepair. During the investigation, LPA Brown obtained evidence to corroborate the allegation. Staffs and residents’ interviews indicated that the two (2) washers and the dryers were broken last 06/2021 that's why staffs were washing residents clothes at the laundry mat. In addition, staff interviews revealed that they were washing residents clothes in laundry mat and it took the facility a month to replace the two (2) broken washers and dryers at the facility. Licensee/Administrator Hamed confirmed to LPA Brown that last 06/2021, the two (2) washers and dryers were broken on a weekend that time but because the repair person cannot go to the facility on a weekend, it was not repaired until that Monday but Licensee/Administrator Hamed was unable to provide LPA Brown documentation of the immediate repair/replacement of the two (2) washers and dryers at the facility. LPA Brown informed Licensee/Administrator Hamed that deficiency will be issued as this pose potential health, safety and personal rights risks to residents in care.

Based on LPA Brown’s observations and records review, the preponderance of evidence standard has been met, and therefore the above allegations of Facility did not obtain appropriate medical care for resident (Allegation #1), and Facility is in disrepair (Allegation #2) are found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code Of Regulations, Title 22, Division 6, Chapter 8 are being cited on the attached LIC 9099 D.

*** Continuation in LIC9099C ***

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 18-AS-20210608161237
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: 04/25/2023
NARRATIVE
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LPA Brown reviewed compliance history and observed that the facility was issued the same deficiency for 87465 Incidental and Medical Care last 11/07/2022 Civil Penalty was assessed for repeat violation within a 12-month period in the amount of $250.00 per citation and will continue to be assessed of $100.00 per day per citation until corrected.

An exit interview was conducted where this report, LIC9099, LIC9099D, LIC421FC and Appeal Rights were discussed and provided to Licensee/Administrator Ebraheem Hamed.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 18-AS-20210608161237
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: 04/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/26/2023
Section Cited
CCR
87465(a)(1)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in...(1)The licensee ...This requirement is not met as evidenced by:
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Licensee stated to submit signed Statement of Understanding on CCR 87465(a)(1) to LPA Brown by POC due date.
Licensee stated to train all staff on CCR 87465(a)(1) and submit Staff Training Log to LPA Brown by POC due date.
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Based on interviews and records review, the Licensee did not comply with the section cited above by failing to assist and obtain medical care follow-up for R1 from 01/2021 to 03/2021which pose imeediate health, safety and personal rights risks to residents in care.
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Type B
05/02/2023
Section Cited
CCR
87303(g)(1)
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87303 Maintenance and Operation (g) Facilities which have machines and do their own laundry shall: (1) Have adequate supplies available and equipment maintained in good repair... This requirement is not met as evidenced by:
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Licensee stated to submit signed Statement of Understanding on CCR 87303(g)(1) to LPA Brown by POC due date.
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Based on interviews and records review, the Licensee did not comply with the section cited above by failing to maintain their two (2) washers and dryers in good repair last 06/2021 which pose potential health, safety and personal rights risks to residents 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: 04/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 7
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
06/08/2021 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210608161237

FACILITY NAME:MEADOWBROOK ASSISTED LIVING, LLCFACILITY NUMBER:
331881058
ADMINISTRATOR:HAMED, EBRAHEEMFACILITY TYPE:
740
ADDRESS:461 E JOHNSTON AVETELEPHONE:
(951) 658-8875
CITY:HEMETSTATE: CAZIP CODE:
92543
CAPACITY:49CENSUS: 33DATE:
04/25/2023
ANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Licensee/Administrator Ebraheem HamedTIME COMPLETED:
11:15 AM
ALLEGATION(S):
1
2
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9
Staff did not assist resident with personal hygiene.
Staff did not meet resident's bathing needs.
Staff did not meet resident's clothing needs.
Staff did not safeguard resident's personal belongings.
INVESTIGATION FINDINGS:
1
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On 04/25/2023 at 10:00 AM, Licensing Program Analyst (LPA) Melody Brown met with Licensee/Administrator Ebraheem Hamed at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office to deliver the findings of the above allegations. LPA Brown explained the purpose of the requested Office Visit. The investigation consisted of observation, interviews and a review of pertinent documentation.

The investigation was conducted by LPA Melody Brown. The investigation consisted of observation and interviews with relevant parties. The first allegation indicates that Staff did not assist resident with personal hygiene. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interviews with staffs and residents indicated that staffs at the facility are assisting residents with their personal hygiene and no incidents happened at the facility that staffs did not assist residents with their personal hygiene. *** Continuation in LIC9099C ***


Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 18-AS-20210608161237
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: 04/25/2023
NARRATIVE
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During the visit last 04/12/2023, LPA Brown observed staffs assisting residents with their personal hygiene.

The second allegation indicates that Staff did not meet resident's bathing needs. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interviews with residents indicated that the staffs are meeting their bathing needs, that staffs are giving them shower. Residents’ interviews revealed no incident happened at the facility that staffs did not meet residents' bathing needs. Staffs’ interviews revealed that they are showering all the residents at the facility and provided LPA Brown their Resident Shower Schedule. During the tour of the facility last 04/12/2023, LPA Brown observed staffs giving shower to residents.

The third allegation indicates Staff did not meet resident's clothing needs. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interviews with residents indicated that the staffs are meeting the residents’ clothing needs. Residents reported to LPA Brown that staffs are washing their clothes weekly and no incident happened at the facility that staffs did not meet their clothing needs. Staffs' interviews indicated that they are washing all residents’ clothes at the facility and no incident happened that they are not meeting their clothing needs. Staffs' interviews revealed that most of the time, they are giving reminders to residents to put some clothes on because there are residents that prefers not to wear a type of clothing for their comfort.

The fourth allegation indicates Staff did not safeguard resident's personal belongings. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interviews with residents indicated that staffs at the facility safeguards their personal belongings, that their personal belongings are safe in their room. Staffs' interviews indicated that they all make sure that residents' personal belongings are safe keep in their rooms. Staffs' interviews revealed that no reports of missing personal belongings from residents at the facility were received.



*** Continuation in LIC9099C ***
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 18-AS-20210608161237
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: 04/25/2023
NARRATIVE
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Based on the evidence, the allegations that Staff did not assist resident with personal hygiene.(Allegation #1), Staff did not meet resident's bathing needs (Allegation #2),Staff did not meet resident's clothing needs.(Allegation #3) and Staff did not safeguard resident's personal belongings (Allegation #4) are UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated at this time.

An exit interview was conducted where this report, LIC9099 was discussed and provided to Licensee/Administrator Ebraheem Hamed .
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 7