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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881058
Report Date: 07/22/2024
Date Signed: 07/22/2024 10:34:36 AM


Document Has Been Signed on 07/22/2024 10:34 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
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: 27DATE:
07/22/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Licensee Ebraheem HamedTIME COMPLETED:
10:40 AM
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The office meeting held today consisted of Community Care Licensing (CCL) staff Regional Manager (RM) Reyna Lacey, Licensing Program Manager (LPM) Jazmond Harris, Licensing Program Analysts (LPAs) Sara Martinez and Debbie Palacios. CCL staff met with Licensee Ebraheem Hamed and administrator Andrea Scott.

During today's meeting, licensee informed CCL staff he was going to rescind the closure plan submitted. The licensee reported another entity has submitted an application for a change of ownership to the Department.

The licensee will submit his request to rescind the closure plan via email by close of business today. Licensee reported the proposed new owner's application should be received by the Department by today. At the request of the licensee, CCL provided a copy of Health & Safety code section 1569.682 was provided, in the event the licensee makes a change to his decision.

An exit interview was conducted where a copy of this report was provided to Licensee Hamed.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 605-0913
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2024
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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