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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881058
Report Date: 03/12/2024
Date Signed: 03/12/2024 04:31:51 PM


Document Has Been Signed on 03/12/2024 04:31 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: 26DATE:
03/12/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Armond Comia, MaintenanceTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Yolanda Delgado conducted an unannounced visit to the facility for a case management visit. LPA met with Maintenance Armond Comia who was informed of the purpose of the visit. LPA contacted Andrea Scott and she is unavailable to come to the facility at this time, she is scheduled to return at the end of the week, she was informed the reason for the visit, Andrea will follow up with Eileen Martinez and call LPA back.

During the time of the visit LPA spoke with Armond that stated the Fire Department wanted Building #3 boarded up, the facility has submitted plans to CCLD and permits to the City to demolish and reconstruct building #3. Building #3 is empty. LPA observed building #3 boarded up/sealed. Armond stated that the Building and Safety wants the facility to fix their electrical issues, there is a due date unknown when. Armond stated that Contractor and Inspector came out to look at the electrical conduits this morning.

LPA conducted a health and safety check on the facility residents. LPA observed residents in living room, outdoor smoking area, and in their bedrooms. LPA observed the kitchen area with commercial size refrigerators not working and dining room with two (2) refrigerators; the facility food supply did not meet the requirements as having a 2 day supply of perishable food items.

Two (2) deficiencies were cited at the time of the visit. An exit interview was conducted with Armond Comia where this report, LIC809D, Appeal Rights was reviewed and provided to them.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda DelgadoTELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2024
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 03/12/2024 04:31 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
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: 03/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/13/2024
Section Cited
HSC
87555(a)(b)(26)

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87555 GENERAL FOOD SERVICE REQUIREMENTS: (a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner. (b) The following food service requirements shall apply:(26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.
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Licesee will obtain groceries for all residents in care and submit receipt to LPA by 8AM POC due date. A plan of grocery shopping, who is in charge of the grocery shopping will need to be sent to LPA by email.
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This requirement is not being met as evidenced by: LPA observed two refrigerators inside the dining room that did not have two days of perishable foods available for all residents in care. The licensee is not ensuring that two days of perishable foods are available at all times; this poses an immediate, safety and personal rights risks to staff and persons in care.
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Type B
03/26/2024
Section Cited
HSC87555(29)

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87555 GENERAL FOOD:
29) All equipment, fixed or mobile, and dishes, shall be kept clean and maintained in good repair and free of breaks, open seams, cracks or chips
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PLAN OF CORRECTION
Licensee to agree to either replace or repair the commercial refrigerator. Statement, invoice or receipts of new purchase or repair to be to be submitted to LPA by 5pm on POC.
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This requirement is not being met as evidenced by: LPA observed silver commercial size refrigerator inside the kitchen that is not working and temporary has two refrigerators inside the dining area being used; this poses an immediate, safety and personal rights risks to staff and persons 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: 03/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2