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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881058
Report Date: 09/05/2023
Date Signed: 09/05/2023 01:07:51 PM


Document Has Been Signed on 09/05/2023 01:07 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
RIVERSIDE AC/SC, 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:
09/05/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Assistant Administrator - Andrea ScottTIME COMPLETED:
01:10 PM
NARRATIVE
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On 9/5/2023, Licensing Program Manager (LPM) Jazmond Harris and Licensing Program Analyst (LPA), Janette Romero arrived unannounced to conduct a Health and Safety Visit to ensure the facility made corrections requested by Sr. Building Inspector, Javier Nolasco from the City of Hemet Fire and Life Safety Agency. LPM and LPA met with Assistant Administrator, Andrea Scott. Fire Prevention Officer, Justine Salas arrived at the facility and conducted a walk through with LPM and LPA .

During the inspection, Fire Inspector stated the following corrections are still required from the previous inspection in March 2023:

Exit signs throughout the facility shall be maintained.

Additional information was provided that the facility is required to make additional corrections. Fire inspector requested the changes be made within 14 days. Documents will be sent to Community Care Licensing for additional review. No additional information was obtained.

During the inspection, LPM and LPA observed a broken window in Building #2's dining area. The facility will be cited for the violation. Assistant Administrator stated the window would be replaced on September 5, 2023. It was requested that the proof of corrections be sent to LPA.

Exit interview conducted. A copy of the report, along with the LIC 9099-D and appeal rights were provided to Assistant Administrator.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2023
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 09/05/2023 01:07 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
RIVERSIDE AC/SC, 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: 09/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/08/2023
Section Cited
CCR
87303(c)

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87303(c) Maintenance and Operation: All window screens shall be clean and maintained in good repair. This requirement was not met as evidenced by:
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Administrator Assistant stated that the broken window will be removed and replaced by September 5, 2023. Proof of correction will be submitted to LPA.
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LPM and LPA observed a broken window in Building #2's dining room. This poses a potential health and safety 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: Janette RomeroTELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2023
LIC809 (FAS) - (06/04)
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