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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881058
Report Date: 08/31/2023
Date Signed: 08/31/2023 12:11:52 PM


Document Has Been Signed on 08/31/2023 12:11 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:
08/31/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:49 AM
MET WITH:Andrea Scott, Administrator AssistantTIME COMPLETED:
11:37 AM
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Licensing Program Analyst (LPA), Yolanda Delgado, conducted an unannounced to the facility to conduct a follow-up Case Management visit pertaining to a visit by CCLD on August 22, 2023 for a fire that took place at the facility on August 20, 2023. The LPA met with Administrator Assistant, Andrea Scott,

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 building #3 to be taped off with yellow caution tape, the building has been boarded up. Administrator advised she has received a letter dated August 22, 2023 from City of Hemet fire & Life Safety Agency that a building inspection is require for building #3 as well as for building #1, #2, #4, offices, laundry and kitchen facilities. LPA did not observed a cable lock near the entrance of building #2.

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: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda DelgadoTELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2023
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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