331881058-4-13-2023-18-AS-JESL-CRBVXW-20230428165014

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331881058
Report Date: 04/13/2023
Date Signed: 04/13/2023 12:22:37 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
04/11/2023 and conducted by Evaluator Javina George

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20230411145240

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: 33	DATE:	04/13/2023
		UNANNOUNCED	TIME BEGAN:	08:27 AM
MET WITH:	Andrea Scott, Assistant Administrator		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Resident was relocated from facility without informed consent.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to commence a complaint investigation regarding the allegation listed above. LPA was greeted and granted entry by Caregiver Odessa Robinson, LPA explained the purpose of the visit and elements of the allegation. The Assistant Administrator Andrea Scott arrived shortly after. The allegation listed above was investigated. The investigation consisted of observation, interviews and a review of pertinent documentation.

Regarding the allegation resident was relocated without informed consent. A review of documentation revealed that Resident #1 (R1) does not have a reposnisble party. R1was admitted to the facility on March 3, 2023 from an unlicensed board and care. Per interview with the pending Licensee Eileen Martinez, she stated that R1 required more care in the form of increased supervision, a 2:1 caregiver to resident ratio, and that there was an issue with their social security. When asked about R1s whereabouts, Eileen stated that R1 was transferred to a skilled nursing facility on April 4, 2023. Eileen stated that there was an assessment completed by her, and the doctor that determined the need for transfer.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023

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 5

Control Number 18-AS-20230411145240

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: 04/13/2023

NARRATIVE

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Interviews revealed that R1 was not transferred to a skilled nursing facility but was transferred to the Sister facility: Grace Family Homes facility #197609733, and that the reason was due to an issue with R1's social security. Further information revealed that R1 does not not always acknowledge when being spoken to and that there was not any transfer paperwork observed informing R1 that they were going to be transfer and the reason for the transfer or relocation. LPA did not observe and was not provided with the assessment to support the alleged need for R1's transfer or relocation. Additionally, the facility did not notify the department of not being able to provide care and supervision, and their plan to relocate R1. Eileen also made a self admission stating that she knew that she should have notified licensing. Based on observation and interviews and record review the allegation of Resident was relocated from facility without informed consent is SUBSTANTIATED. A substantiated finding means that the preponderance of evidence standard has been met; therefore, the above allegation is found to be Substantiated.

An exit interview was conducted, and a copy of this report 9099D, and appeal rights were reviewed and provided to Assistant Administrator Andrea Scott.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20230411145240

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: 04/13/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/27/2023 Section Cited CCR 87223(a)(3)	1 2 3 4 5 6 7	87223 Relocation of the Resident (a) when a resident must be relocated...The Licensee shall not obstruct the relocation process and shall cooperate with the department in the relocation process. Such cooperation shall include, but not limited to, the	1 2 3 4 5 6 7	This poses a potential health, safety and personal rights risk to persons in care.
	8 9 10 11 12 13 14	following activities:(3) contacting other suitable facilities for placement, if necessary. This requirement is not met as evidenced by: R1 was relocated without the proper assessment to determine what the services the facility couldn't offer, that would be suitable to meet the residents needs...	8 9 10 11 12 13 14	The licensee agrees to conduct a staff traing on providing care and supervision and specifics of not being able to provide the resident the needed services. Proof is to be submitted to the department by 5pm.
	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: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5

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
04/11/2023 and conducted by Evaluator Javina George

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20230411145240

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: 33	DATE:	04/13/2023
		UNANNOUNCED	TIME BEGAN:	08:27 AM
MET WITH:	Andrea Scott, Assistant Administrator		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff retained resident's personal belongings during relocation.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to commence a complaint investigation regarding the allegation listed above. LPA was greeted and granted entry by Caregiver Odessa Robinson, LPA explained the purpose of the visit and elements of the allegation. The Assistant Administrator Andrea Scott arrrived shortly after. The allegation listed above wasinvestigated. The investigation consisted of observation, interviews and a review of pertinent documentation.

Regarding the allegation staff retained resident's personal belongings during relocation. Resident #1(R1) was admitted to the facility on March 3, 2023 from an unlicensed board and care. A review of R1s residential file, a personal property and inventory sheet was not completed. However per the interview with the assist administrator Andrea Scott stated that R1 was admitted to the facility with only two (2) pairs of jogging pants, a few shirts, and one (1) pair of shoes. R1 is incontinent of both bowel and bladder, and wears diapers therefore does not have any underwear, but had diapers. R1 was also admitted to the facility with an accordian file folder that held their Indentification card and insurance card, including other documents.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023

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

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 18-AS-20230411145240

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: 04/13/2023

NARRATIVE

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Additional interviews revealed that R1 was admitted to the sister facility with the items described/noted by the Administrator Andrea. In addition a review of documentation revealed for R1 to be in possession of their personal belongings. Based on interviews and record review, the allegation of resident's personal belongings during relocation is UNFOUNDED. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Therefore, the department had there dismissed the complaint.

An exit interview was conducted and a copy of this report was reviewed and provided to Assistant Administrator Andrea Scott.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5