<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881058
Report Date: 07/12/2024
Date Signed: 07/12/2024 10:25:06 AM


Document Has Been Signed on 07/12/2024 10:25 AM - 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:
07/12/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Andrea Scott, AdministratorTIME COMPLETED:
10:30 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Yolanda Delgado conducted an unannounced visit to the facility in order to conduct a case management visit. LPA met with Virginia Smith, Caregiver who was informed of the purpose of the visit. Administrator, Andrea Scott is on her way. 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. The purpose of the visit was to obtain and update on the fire clearance for the structure that no longer can be used for laundry services. LPA observed red tags attached on all doors for the laundry/storage building issued by Hemet Fire Department on 6/26/2024, LPA observed a door unlocked and a washer was being used with clothes inside. Caregiver went to locate who is doing laundry and stated a resident was using it. LPA requested documentation of notification to residents and staff that the structure is not to be used. Andrea stated that laundry services are contracted through Laundster Co.

One deficiency were cited at the time of the visit. An exit interview was conducted with Administrator, Andrea Scott where this report, 809-D and Appeal Rights 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: 07/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2024
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 07/12/2024 10:25 AM - 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: 07/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/13/2024
Section Cited
HSC
87203

1
2
3
4
5
6
7
FIRE SAFETY: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement was not being met as
1
2
3
4
5
6
7
Licensee will ensure the building is secured and inaccessible to residents for use, conduct a a meeting with staff/residents regarding the building not to be used and email plan to LPA by POC due date.
8
9
10
11
12
13
14
evidenced by: LPA Delgado observed a door unlocked and one wash machine in use. Hemet Fire Department deemed building not safe to enter and unsafe to occupy on 6/26/2024. This poses a potential health and safety risk 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: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda DelgadoTELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2