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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881058
Report Date: 11/01/2023
Date Signed: 11/01/2023 11:43:00 AM


Document Has Been Signed on 11/01/2023 11:43 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
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: 29DATE:
11/01/2023
TYPE OF VISIT:Case Management - DeficienciesANNOUNCEDTIME BEGAN:
11:21 AM
MET WITH:Andrea Scott, AdministratorTIME COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Yolanda Delgado met with Administrator Andrea Scott at the Riverside Regional Office for a Case Management deficiencies visit. LPA explained the purpose of the visit with Andrea Scott.

LPA conducted an investigation for complaint control number 18-AS-20210309144045. During the investigation it was revealed that the facility failed to follow reporting requirements. A records review revealed that residents eloped from the facility and it was not reported to CCLD. LPA conducted interviews with staff and review of records for residents #1, #2, #3 (R1, R2, R3) had eloped away from the facility and it was not reported.
A deficiency is being cited per Title 22, Division 6, Chapter 8, Article 4 CCR 87211 (1) (D) of the California Code of Regulations.

An exit interview was conducted and a copy of this report, 809-D, Appeal Rights and the confidential names list (LIC811), was provided to Andrea Scott.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda DelgadoTELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 11/01/2023 11:43 AM - 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: 11/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/08/2023
Section Cited
CCR
87211(1)(D)

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REPORTING REQUIREMENTS:
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below...(D) Any incident which threatens the welfare, safety or health of any resident...unexplained absence of any resident.
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Licensee will read section CCR 87211 and will submit SIR’s for any resident that elope or wander away. Proof of self-certification of acknowledgement and understanding of CCR 87211 will be submitted to licensing by the date of POC.
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This requirement was not being met as evidenced by: During interviews and records review it was revealed that Residents #1, #2, #3 had eloped from the facility and Licensee failed to send a written report to CCLD. This poses an immediate health and safety risk to residents 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: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda DelgadoTELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2023
LIC809 (FAS) - (06/04)
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