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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881058
Report Date: 06/12/2023
Date Signed: 06/12/2023 03:27:15 PM


Document Has Been Signed on 06/12/2023 03:27 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: 33DATE:
06/12/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Eileen Martinez, Licensee and Andrea Scott, AdministratorTIME COMPLETED:
03:00 PM
NARRATIVE
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On today's date an informal meeting was held with Licensing Program Analyst (LPA) Javina George and Licensing Program Manager (LPM) Joel Esquivel met with the Licensee Eileen Martinez, and Administrator Andrea Scott. The following issues were discussed:

-Substantiated complaint findings for complaints received.
-The resident's and their personal rights
-The eviction process and when it should and needs to be implemented
-Both the Licensee and Administrator were encouraged to review Title 22 regulations
-Both the Licensee and Administrator were provided with another copy of the Notice To Long Term Care Facilities regarding Ombudsman Access to Facilities, Residents, and Records.
-The Technical Support Program(TSP) was discussed and offered as a resource, during today's meeting the offer was not accepted, however as the Ms. Martinez will think about it, and contact the office should she change her mind.

Through discussion of the issues it was revealed that the Licensee did not follow the proper steps for evicting Resident #1 (R1), as a result a deficiency will be cited. The Licensee agreed to provide an update in regards to R1 and their whereabouts by June 16, 2023.

An exit interview was conducted with the Licensee Eileen Martinez, and a copy of this report was reviewed and provided along with the 809D and appeal rights.

SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2023
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 06/12/2023 03:27 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: 06/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/26/2023
Section Cited
CCR
87224

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87224 Eviction procedures
(a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph
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This requirement is not met as evidenced by: 1 out 1 times the licensee did not complete a reassesment of R1 and relocated them without justification, This poses a potential health, safety and personal rights risk to persons in care.
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(4) If, after admission, it is determined that the resident has a need not previously identified and a reappraisal has been conducted pursuant to Section 87463, and the licensee and the person who performs the reappraisal believe that the facility is not appropriate for the resident.
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The Licensee agrees to complete statement of understaning about the eviction procedures. In addtion the licensee agrees to obtain an update in reagrds R1 and their wherearbouts.

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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: 06/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2023
LIC809 (FAS) - (06/04)
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