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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881058
Report Date: 12/12/2023
Date Signed: 12/12/2023 12:10:25 PM


Document Has Been Signed on 12/12/2023 12:10 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 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: 29DATE:
12/12/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:37 AM
MET WITH:Andrea Scott, AdministratorTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Javina George made an unannounced case management deficiencies visit. LPA went to the facility to deliver findings for a complaint that is associated with the facility, due it being the same location. However due to a change of ownership, a new license number was issued. LPA observed the following deficiencies:

At the time of LPAs visit, the facility food supply did not meet the requirements as having a 2 day supply of perishable, and a 7 day supply of non perishable food items. Proof of purchase is to be provided to LPA by 5:00pm on today's date. A citation was not issued as facility staff went shopping during LPAs visit.

LPA conducted interviews and it was reported that the facility has bed bugs. LPA observed for there to be 3 bottle of bed bug killer inside the staff office. LPA conducted a tour of the interior of the facility and observed for some mattresses to not be in plastic as reported. Facility staff went to the store to purchase mattress covers during LPAs visit. Proof of the purchase it to be provided to LPA by 5:00pm on today's date.

The facility staff stated that precautions are being taken to rectify the bed bug issue, however the exterminator has not been out to the facility, a date could not be provided as to when the last time the exterminator had come out. Per Administrator Andrea Scott the facility is having a barbecue tomorrow 12/13/23, and while the residents are enjoying the festivities the building will be bombed, the heat turned up and steamed. Andrea reported that the facility has taken precautions to rid the facility of bed bugs as there were identified cracks that were recently sealed on 12/11/23.
LPA observed three residents to have bites on their body, as well as scratches. Resident's also reported having bed bugs in their hair. Per conducted interviews the facility has had bed bugs for at least three (3) months. Based on reports from the residents, observation of visible bites and scratches, bed bug spray as well as self admission of bed bugs, a deficiency is binge issued on the attached 809D, in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8).
An exit interview was conducted, and copy of appeal rights were provided to Andrea Scott, Administrator.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2023
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 12/12/2023 12:10 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 ASC, 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: 12/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/13/2023
Section Cited
HSC
1569.269(a)(5)

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156.265 (a)(5) ENUMERATED RIGHTS: SEVERABILITY Residents of residential care facilities for the elderly shall have all of the following rights: To be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment.
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The Licensee is to ensure the exterminator treats the facility. The licensee states all rooms will be treated. The licensee agress to submit receipts or contract to CCL by 5 pm on the due date . indicated
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This regulation was not met as evidenced by: The facility has an on going infestation. This posed 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: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2023
LIC809 (FAS) - (06/04)
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