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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881058
Report Date: 05/01/2023
Date Signed: 05/01/2023 04:34:33 PM


Document Has Been Signed on 05/01/2023 04:34 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: 32DATE:
05/01/2023
TYPE OF VISIT:Case Management - DeficienciesANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Licensee/Administrator Ebraheem HamedTIME COMPLETED:
04:45 PM
NARRATIVE
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On 05/01/2023 at 04:00 PM, 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 initiate a Case Management - Deficiency. LPA Brown explained the purpose of the requested Office Visit.

During the facility visit last 04/28/2023, LPA Brown toured the facility with Assistant Administrator Andrea Scott and observed broken stucco along the walls on Building #2. LPA Brown informed Licensee/Administrator Hamed that deficiency will be issued as this pose potential risk to clients in care.

An exit interview was conducted where this report LIC809, LIC809D, 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: 05/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2023
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 05/01/2023 04:34 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: 05/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/30/2023
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... This requirement is not met as evidenced by:
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Licensee stated to make the necessary repairs to remain in compliance with continued maintenance of the facility. Licensee shall complete estimates for repairs, schedule repairs, complete repairs by the POC due date of 05/30/2023 and submit proof to LPA Brown.
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Based on observation and interview, the Licensee did not comply with the section cited above by having a broken stucco along the walls on Building #2 of the facility which pose potential health, safety and personal rights risk to residents in care.
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Licensee stated to submit signed Statement of Understanding on CCR 87303(a) and submit to LPA Brown by POC due date.

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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: 05/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2023
LIC809 (FAS) - (06/04)
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