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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881058
Report Date: 05/18/2023
Date Signed: 05/18/2023 09:47:10 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
05/16/2023 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230516161135
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:
05/18/2023
UNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Andrea Scott, Assistant AdministratorTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Staff did not allow the Long Term Care Ombudsman to enter the facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to commence a complaint investigation for the allegation listed above. LPA met with Andrea Scott, Assistant Administrator and explained the purpose of the visit and the elements of the allegation. The allegation was investigated. The investigation consisted of observations, interviews and record review.

Regarding the allegation of Staff did not allow the Long Term Care Ombudsman to enter the facility It was reported that on or around May 17, 2023 the Long Term Care Ombudsman (LTCO), attempted to conduct a routine visit at the facility. However, upon arrival the LTCO and Assistant Administrator Andrea was informed by the new pending Licensee Eileen Martinez via telephone that she wanted a new LTCO, and did not permit the LTCO from entering the facility. LPA spoke with Ms. Martinez via telephone who admitted that she did in fact instruct for staff to not allow the LTCO to enter the facility. Based on self-admission by Ms. Martinez, the allegation of staff did not allow the Long Term Care Ombudsman to enter the facility is SUBSTANTIATED.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023
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 3
Control Number 18-AS-20230516161135
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: 05/18/2023
NARRATIVE
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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, where a copy of the report, LIC9099D, and appeal rights were reviewed and provided to Andrea Scott, Assistant Administrator.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 18-AS-20230516161135
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: 05/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/01/2023
Section Cited
CCR
87468.1(a)(11)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (11) To have their visitors, including ombudspersons and advocacy representatives, permitted to visit
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The licensee agrees to conduct a staff training on the LTCO and their right to access the facility. Proof of correction is to be submitted to the departmnet by 5pm on the due date indicated.
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privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon. This requirement is not met as evidenced by: the licensee did not allow the LTCO to enter the facility. This poses a potential health, safety and personal rights risk to persons 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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3