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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881058
Report Date: 08/22/2023
Date Signed: 08/22/2023 11:36:48 AM


Document Has Been Signed on 08/22/2023 11:36 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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:
08/22/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Andrea Scott, Administrator AssistantTIME COMPLETED:
11:40 AM
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Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to follow up on a fire that took place at the facility on August 20, 2023. The LPA met with Administrator Assistant, Andrea Scott, and informed her of the purpose for her visit.

The Department was notified of the fire via telephone call and via Unusual Incident Report on August 21, 2023. The report stated a building, not occupied by residents, caught fire and the fire department was contacted for assistance. During the visit, the LPA inspected the exterior areas of the building (the fire department deemed the building unsafe to occupy). The LPA observed the roof, exterior walls, and windows to be damaged. Burned furniture, debris, and other items were observed surrounding portions of the walkways just outside of the building. No measures were observed to be in place to ensure the walkways were cordoned off. However, during the visit the LPA observed personnel with Fire Prevention arrive and begin to place caution tape around the building. Staff/resident interviews reported no residents occupies the building that caught fire. In addition, during the visit it was reported facility staff lock one of three exit routes in building two during the night due to the door not staying locked. The LPA observed a cable lock wound around a rail near the main entrance of building two. Staff and resident interviews reported the night staff use the lock on the door because it does not stay locked. The Administrator Assistant was interviewed and corroborated the statements. She stated the lock was used to ensure the homeless who walk around the premises could not enter the building. She reported the lock is no longer being used and removed the lock from the rail. Justine Salas, Fire Prevention Officer, was consulted and reported a lock should not be placed on the door of such a building; however, due to the building having two alternate exit routes the lock being used is not an immediate concern.

No additional health and safety concerns were observed at time of visit. This report was reviewed with Administrator Assistant Scott and a copy was provided.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) -24-0313
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2023
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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