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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881058
Report Date: 12/28/2023
Date Signed: 12/28/2023 01:11:50 PM


Document Has Been Signed on 12/28/2023 01:11 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
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: DATE:
12/28/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Administrator, Andrea ScottTIME COMPLETED:
01:20 PM
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced visit to the facility in order to conduct a case management visit. LPA met with Administrator, Andrea Scott who was informed of the purpose of the visit.

During the time of the visit LPA conducted interviews, conducted a walk through of the interior and exterior of the facility, and requested pertinent documents.

LPA conducted a health and safety check on the facility residents. LPA observed resident in living room, outdoor smoking area, and in their bedrooms. LPA observed no health or safety issues during the time of the visit.

LPA spoke with staff about fire that occurred in building #3 of the facility. The purpose of today's visit was to obtain documentation and inspection reports on the fire and progress of repairs and correction from visit conducted on 9/5/2023. Based on staff and resident interviews, it was found that the fire occurred in a building which did not house any residents. LPA observed and took photos of the building which is boarded and still shows fire damage. LPA spoke with the Licensee, Eileen Martinez over the phone during the visit and was informed the facility has secured permits and contractor and is currently waiting on insurance funds to rebuilding. LPA requested the licensee send Fire inspection report to them for review. LPA observed corrections implemented during the visit such as evacuation routes, and Exit signs at facility exits. LPA also tested the smoke alarms in the rooms 15, 20, 21, 22, 25, and 26 which were operational during the time of the visit.

No deficiencies were cited at the time of the visit. An exit interview was conducted with Administrator, Andrea Scott where this report was reviewed and provided to them.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 12/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2023
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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