331881058-4-11-2022-18-AS-DMUN-CDR4N5-20220422191432

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331881058
Report Date: 04/11/2022
Date Signed: 04/11/2022 12:51:08 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/05/2022 and conducted by Evaluator Tricia Danielson

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20220405103048

FACILITY NAME:	MEADOWBROOK ASSISTED LIVING, LLC		FACILITY NUMBER:	331881058
ADMINISTRATOR:	HAMED, EBRAHEEM		FACILITY TYPE:	740
ADDRESS:	461 E JOHNSTON AVE		TELEPHONE:	(951) 658-8875
CITY:	HEMET	STATE: CA	ZIP CODE:	92543
CAPACITY:	49	CENSUS: 40	DATE:	04/11/2022
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Ebraheem Humed, Administrator		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Resident had access to razor blades while in care

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Tricia Danielson and Chinwe Nwogene arrived unannounced to the facility to initiate an investigation into the allegation listed above. LPAs met with Med Tech Liliana Alvarez and explained the purpose of the visit. Administrator Ebraheem Hamid and Tommy Jarad arrived prior to LPA's departure.
During today's visit, LPAs interviewed Resident #1 (R1), two (2) staff, reviewed and obtained copies of pertinent documents as well as toured R1's room and bathroom. Regarding the allegation "Resident had access to razor blades while in care", it was alleged that R1's condition prohibited them from having access to razor blades. Interview with R1 revealed they perform their own personal hygiene and receive razors from their spouse. Review of R1's records revealed R1 is not at risk in having access to personal hygiene items. This agency has investigated the complaint alleging "Resident had access to razor blades while in care". We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and is without a reasonable basis. We have therefore dismissed the complaint.
An exit interview was conducted with Jarad and a copy of this report was provided along with LIC 811- Confidential Names List.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/05/2022 and conducted by Evaluator Tricia Danielson

COMPLAINT CONTROL NUMBER: 18-AS-20220405103048

FACILITY NAME:	MEADOWBROOK ASSISTED LIVING, LLC		FACILITY NUMBER:	331881058
ADMINISTRATOR:	HAMED, EBRAHEEM		FACILITY TYPE:	740
ADDRESS:	461 E JOHNSTON AVE		TELEPHONE:	(951) 658-8875
CITY:	HEMET	STATE: CA	ZIP CODE:	92543
CAPACITY:	49	CENSUS: 40	DATE:	04/11/2022
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Tommy Jarad, Manager		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Resident's personal living area is not maintained with cleanliness

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Tricia Danielson and Chinwe Nwogene arrived unannounced to the facility to initiate an investigation into the allegation listed above. LPAs met with Med Tech Liliana Alvarez and explained the purpose of the visit. Administrator Ebraheem Hamid and Tommy Jarad arrived prior to LPA's departure.
During today's visit, LPAs interviewed Resident #1 (R1), two (2) staff, reviewed and obtained copies of pertinent documents as well as toured R1's room and bathroom. Regarding the allegation "Resident's personal living space is not maintained with cleanliness", it was alleged that in R1's bathroom, the toilet, sink, and floor were filthy. It was also alleged that R1's sink was piled high with razors with some of them being rusty. Additionally, it was alleged that R1's room smelled of urine and their bed sheets had a foul odor. LPAs toured R1's room and bathroom and observed half smoked cigarettes on the dresser, open packs of razors, some of which had been used and were visibly covered in gray hair, plastic food wrappers on the floor, full trash can, food crumbs on the floor beneath the bed, soiled towels hanging in the bathroom, empty soda can on the dresser, dirty bathroom window seal, window screen leaning against the bathroom wall, mildew and soap scum in the shower, dirty toilet seat and bowl, dirty bathroom floor, and a (CONTINUED ON LIC 9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20220405103048

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 04/11/2022

NARRATIVE

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(CONTINUED FROM LIC 9099A)
red gummy substance all over the bathroom sink. LPAs also observed R1's room to be malodorous with urine smell. A room air freshener was noted to be on R1's dresser.
Interview with Staff #1 (S1) revealed they are responsible for housekeeping at the facility along with one other staff but are only called upon by the facility when needed. Based on LPA's observations, interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code Of Regulations, Title 22, Division 6, Chapter 8 are being cited on the attached LIC 9099 D.

An exit interview was conducted with Alvarez and a copy of this report was provided along with LIC 811- Confidential Names List and Appeal Rights.

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2022

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20220405103048

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/11/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/22/2022 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	Maintenance and Operation- (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Facility states they will submit a statement of understanding of the regulation cited by POC date of 4/22/22. Facility will provide virtual tour of R1's bathroom and room by POC due date.
	8 9 10 11 12 13 14	The facility did not ensure R1's personal living space was maintained with cleanliness. Based on LPA observations, R1's room and bathroom were found to be unclean and malodorous. This poses a potential health, safety, and personal rights risks to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Deborah Mullen	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2022

LIC9099 (FAS) - (06/04)

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