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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881058
Report Date: 08/12/2024
Date Signed: 08/12/2024 01:16:33 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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
09/01/2021 and conducted by Evaluator Sara Martinez
COMPLAINT CONTROL NUMBER: 18-AS-20210901132614
FACILITY NAME:MEADOWBROOK ASSISTED LIVING, LLCFACILITY NUMBER:
331881058
ADMINISTRATOR:HAMED, EBRAHEEMFACILITY TYPE:
740
ADDRESS:461 E JOHNSTON AVETELEPHONE:
(951) 658-8875
CITY:HEMETSTATE: CAZIP CODE:
92543
CAPACITY:49CENSUS: 27DATE:
08/12/2024
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Administrator - Andrea ScottTIME COMPLETED:
01:25 PM
ALLEGATION(S):
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Resident is being mistreated while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sara Martinez arrived unannounced to the facility to conclude the investigation into the allegation listed above. LPA met with Administrator Andrea Scott and explained the purpose of the visit. LPA’s complaint investigation consisted of a tour of the interior/exterior areas of the facility, observations, interviews with staff and residents, and records review of requested pertinent documents.

Regarding the allegation “Resident is being mistreated while in care”, it was reported staff are not providing the necessary care needed for Resident One (R1) and staff are using inappropriate language towards the residents in care. Records review of R1’s Physician’s Report revealed R1 has the capability to perform their activities of daily living (ADL) on their own with no assistance needed from staff. Records review of R1’s Pre-Appraisal reveal R1 is ambulatory with a walking device and has the capability of going in and out of the facility unassisted by staff. Interview with two (2) staff who worked at the facility in September 2021 reported R1 was ambulatory and did not require assistance from staff to perform R1’s ADLs and denied witnessing staff use inappropriate language towards the residents in care.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 605-0913
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 18-AS-20210901132614
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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, LLC
FACILITY NUMBER: 331881058
VISIT DATE: 08/12/2024
NARRATIVE
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Interview with four (4) residents who resided at the facility in 2021 denied staff using inappropriate language towards R1 or the other residents in care. LPA interviewed five (5) residents in total who denied witnessing staff using inappropriate language towards the residents in care. LPA was not able to interview R1 due to contact information not available. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided to Administrator Andrea Scott.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 605-0913
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2