331881058-4-28-2023-18-AS-EMAN-CREMMD-20230501094347

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331881058
Report Date: 05/23/2022
Date Signed: 04/28/2023 04:45:18 PM

Unsubstantiated

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
05/19/2021 and conducted by Evaluator Jennifer Semin

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210519143050

FACILITY NAME:	MEADOWBROOK ASSISTED LIVING, LLC		FACILITY NUMBER:	331881058
ADMINISTRATOR:	HAMED, EBRAHEEM		FACILITY TYPE:	740
ADDRESS:	461 E JOHNSTON AVE		TELEPHONE:	(951) 658-8875
CITY:	HEMET	STATE: CA	ZIP CODE:	92543
CAPACITY:	49	CENSUS: 38	DATE:	05/23/2022
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Assistant Administrator Andrea Scott		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Facility is not allowing a resident to have visitors
Staff failed to provide residents with privacy
Staff are mismanaging residents' medication
Staff failed to provide a safe environment for the residents

INVESTIGATION FINDINGS:

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On 04/28/2023, Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the facility to amend the report for the above complaint allegations delivered by LPA Jennifer Semin last 05/23/2022 with Administrator Ebraheem Hamed.

The investigation consisted of interviews and review of pertinent documents. The first allegation indicates that Facility is not allowing a resident to have visitors. Relevant Party (RP) stated they were denied visitation with resident. Interviews with staff revealed staff do not deny residents visitors. Staff 1 (S1) stated there was one occasion when Resident 1 (R1) had a visitor come at 11:45pm after visitors’ hours. The visitor stated it was a non-emergency visit and staff did direct them to return during visiting hours as R1 was asleep. R1 was not aware of a visitor that was turned away.
***Continuation in LIC9099C ***
*** This is an Amendment of LIC9099 Issued last 05/23/2022 by LPA Jennifer Semin ***

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

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 4

Control Number 18-AS-20210519143050

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: 05/23/2022

NARRATIVE

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The second allegation indicates Staff failed to provide residents with privacy. RP stated male and female residents have been sharing bathrooms for a long time and they don’t have any privacy. Residents’ interviews indicated there is no privacy issue at the facility as all the bedrooms that have a shared bathroom between them have the same gender residents on both sides. Staffs’ interviews revealed that there is no privacy issue at the facility as no bedrooms that share a restroom with opposite gender residents on either side at the facility. Moreover, interviews with residents and staffs indicated no incidents happened at the facility that privacy issue was reported.

The third allegation indicates Staff are mismanaging residents' medication. RP stated residents’ medications are left out in the medication room and it is not always locked. Interviews with staff revealed the resident’s medication is stored in medication carts and in locked cabinets in the medication room that is locked and behind an additional locked door. Residents 1-7 stated the medication room behind a locked door that is through the med room office door, which is locked. R1, R2, R3, R4, R5, R6, and R7 stated the medication is passed from a locked medication cart that the med person rolls into the hall or room of the person getting the medication.

The fourth allegation indicates Staff failed to provide a safe environment for the residents. RP stated staff sometimes leave the medication room unlocked and it creates an unsafe environment for residents. Interviews with staff and residents revealed the medication room is behind 2 locked doors. Staff stated they always lock the medication room door and the office door when they are not present.

Based on the evidence, the allegation that Facility is not allowing a resident to have visitors (Allegation #1), Staff failed to provide residents with privacy (Allegation #2), Staff are mismanaging residents' medication (Allegation #3), and Staff failed to provide a safe environment for the residents (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 was discussed and provided to Assistant Administrator Andrea Scott.
*** This is an Amendment to LIC9099 Issued last 05/23/2022 by LPA Jennifer Semin ***

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
05/19/2021 and conducted by Evaluator Jennifer Semin

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210519143050

FACILITY NAME:	MEADOWBROOK ASSISTED LIVING, LLC		FACILITY NUMBER:	331881058
ADMINISTRATOR:	HAMED, EBRAHEEM		FACILITY TYPE:	740
ADDRESS:	461 E JOHNSTON AVE		TELEPHONE:	(951) 658-8875
CITY:	HEMET	STATE: CA	ZIP CODE:	92543
CAPACITY:	49	CENSUS: 38	DATE:	05/23/2022
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Assistant Administrator Andrea Scott		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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9

Facility is in disrepair

INVESTIGATION FINDINGS:

1
2
3
4
5
6
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9
10
11
12
13

On 04/28/2023, Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the facility to amend the report for the complaint allegations delivered by LPA Jennifer Semin last 05/23/2022 with Administrator Ebraheem Hamed.
The investigation consisted of interviews and review of pertinent documents. The allegation indicates Facility is in disrepair. Staff and residents stated there was no tub or sink that was clogged or was slow draining and no shower head broken. During the visit last 04/28/2023, LPA Brown toured the facility with Assistant Administrator Scott and physically checked residents bathrooms and observed no resident shower head and bath tub were in disrepair. Based on the evidence, the allegation that Facility is in disrepair is 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 Assistant Administrator Andrea Scott.
***This is an Amendment of LIC9099 Issued last 05/23/2022 by LPA Jennifer Semin ***

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

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

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 18-AS-20210519143050

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: 05/23/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/30/2023 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	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 was not met as evidenced by:	1 2 3 4 5 6 7	Licensee shall make the necessary repairs to remain in compliance with continued mainenance of the facility. Licensee shall complete estimates for repairs and schedule repairs by the POC due date of 5/30/2023.
	8 9 10 11 12 13 14	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 a potential health, safety and personal right risk to residents in care.	8 9 10 11 12 13 14	*Request LIC9099D to be deleted due to UNSUBSTANTIATED findings....* Deficiency will be issued in LIC809D on 05/01/2023 at 4:00 PM during scheduled Office Visit with LIcensee/Administrator Ebraheem Hamed
	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: Efren Malagon	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 4