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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881058
Report Date: 02/27/2024
Date Signed: 02/27/2024 03:27:22 PM


Document Has Been Signed on 02/27/2024 03:27 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: 28DATE:
02/27/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Andrea Scott, AdmninistratorTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Yolanda Delgado conducted an unannounced Case Management Incident visit. LPA was greeted and granted entry by Armond Comia, Maintenance. LPA explained the purpose of the visit and toured the facility. The visit is in response to the death of Resident #1 (R1), that was reported on 02/26/2024 to have passed away. Armond contacted Andrea Scott on the telephone, she advised she is away from the facility and it will take her 1 hour to arrive.

During LPA's visit, LPA reviewed R1's file and obtained copies of the following: ID/emergency Information, admission agreement, Physician's report, Psychiatric notes, Appraisal/Needs and Services Plan, Preplacement appraisal information, centrally destroyed medication and destruction record, physician's orders and medication records (MARs) was not available due to other agency being given the original. LPA also requested a copy of R1s death certificate when it is made available and a copy of the MARS.

During today's visit no deficiencies were cited.

An exit interview was conducted, and a copy of this report was provided to Andrea Scott along with a copy of the LIC811.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda DelgadoTELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2024
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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