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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881058
Report Date: 02/13/2024
Date Signed: 02/13/2024 01:52:54 PM


Document Has Been Signed on 02/13/2024 01:52 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: 29DATE:
02/13/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Ebraheem Hamed, LicenseeTIME COMPLETED:
02:00 PM
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On February 13, 2024, an office meeting was conducted regarding the change of use of the facility. In attendance for the meeting was Regional Manager, Reyna Lacey (RM), Licensing Program Manager (LPM), Jazmond Harris, Licensing Program Analyst (LPA), Yolanda Delgado, Licensee Ebraheem Hamed, Assistant Administrator Andrea Scott.

The Department provided and reviewed Health and Safety Code section 1569.682 and PIN 18-17-ASC for guidance on facility closure requirements. The licensee advised that he lost control of the property effective October 21, 2021. The licensee advised the property is now leased to the potential new owner. The licensee advised the new owner has submitted a new application for licensure however the application has not been approved. The licensee reported he may gain control of the property back. The licensee must submit proof of control of property February 20, 2024.

The Department provided guidance should the licensee chose to close which included the licensee submitting a closure plan. The licensee understands that the licensee cannot issue a notice of transfer until the Department approves the closure plan. The licensee reported they are currently not accepting new admissions.

An exit interview was conducted; where this report was reviewed and provided to Licensee.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda DelgadoTELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024
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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