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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881058
Report Date: 04/30/2024
Date Signed: 04/30/2024 03:47:46 PM


Document Has Been Signed on 04/30/2024 03:47 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: 29DATE:
04/30/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
03:33 PM
MET WITH:Andrea Scott, Assistant AdministratorTIME COMPLETED:
03:50 PM
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On 4/30/2024, Licensing Program Analyst (LPA) Jacqueline Shaw Ross 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 a health and safety check on the facility residents. LPA observed residents in living room, outdoor smoking area, and in their bedrooms. LPA observed no health or safety issues during the time of the visit.

The purpose of the visit was to obtain and update of the progress of building 3 repairs from a fire that occurred on 8/22/2023. Andrea stated she is not sure when the repairs will be completed, but in the meantime, residents continue to remain away from the building. LPA observed and took photos of the building which is boarded and still shows fire damage. LPA spoke with Armond Cumia, Maintenance Technician, and was informed that the interior of the building has been gutted and progress is being made.

LPA observed corrections implemented during the visit such as evacuation routes, and Exit signs at facility exits.

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.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw RossTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:
DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/30/2024
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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