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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881058
Report Date: 06/12/2024
Date Signed: 06/12/2024 03:55:25 PM


Document Has Been Signed on 06/12/2024 03:55 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: 27DATE:
06/12/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Armond Comia, MaintenanceTIME COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA) Yolanda Delgado conducted an unannounced visit to the facility in order to conduct a case management visit. LPA met with Armond Comia, Maintenance who was informed of the purpose of the visit. Administrator, Andrea Scott is away from the facility. Andrea Scott arrived during 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 the progress of building 3 repairs from a fire that occurred on 8/22/2023. Armond stated the insurance claim is requesting bids for a contractor and the insurance company will determine the reconstruction of building 3. Armond stated that Justine Salas with Hemet Fire Department shared that Building 3 is excluded temporary from Building and Safety for final inspection on June 20, 2024 due to building 3 under insurance claim process to reconstruct the building. Residents continue to remain away from the building. LPA observed building 3 is boarded up with tarps on the roof.

LPA requested and receive Hemet Fire Department inspection reports dated 10/24/2022 and 10/3/2023.

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: Yolanda DelgadoTELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024
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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