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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881058
Report Date: 05/02/2022
Date Signed: 05/02/2022 03:19:32 PM


Document Has Been Signed on 05/02/2022 03:19 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:HAMED, EBRAHEEMFACILITY TYPE:
740
ADDRESS:461 E JOHNSTON AVETELEPHONE:
(951) 658-8875
CITY:HEMETSTATE: CAZIP CODE:
92543
CAPACITY:49CENSUS: 39DATE:
05/02/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Linda Speller, Caregiver
Liliana Alvarez, Med Tech		TIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Tricia Danielson conducted an unannounced plan of correction (POC) visit to verify corrections of citations issued during a previous visit. LPA met with Med Tech Liliana Alvarez and Caregiver Linda Speller.

The following deficiency was not corrected by the POC due date nor has it been corrected at the time of this visit. Civil penalties are being assessed and will continue to accrue until correction has been submitted:

Deficiency cited 4/22/2022 under California Code of Regulations Section 87303(a)- Maintenance and Operation. POC was that the Licensee submit a statement of understanding of the regulation cited and provide virtual tour of R1's bathroom and room by POC due date of 4/22/2022. The Licensee is required to submit proof of completion of the POC in order to clear this deficiency. Civil penalties assessed today at the rate of $100 per day that the deficiency remains uncleared. Today's civil penalty assessment of $1,000 is for the period of 4/23/2022 through 5/2/2022. Civil penalties will continue to accrue at the rate of $100 per day until submission and approval of proof of POC. This deficiency was also previously cited on 5/7/2021, therefore an immediate civil penalty is assessed today in the amount of $250.00 for a repeated violation.
An exit interview was conducted with Speller and a copy of this report, LIC421FC, and appeal rights were provided.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2022
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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