331881058-5-18-2022-18-AS-TDAN-CEJRJC-20220518130340

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881058
Report Date: 05/18/2022
Date Signed: 05/18/2022 01:05:21 PM

Document Has Been Signed on 05/18/2022 01:05 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, LLC		FACILITY NUMBER:	331881058
ADMINISTRATOR:	HAMED, EBRAHEEM		FACILITY TYPE:	740
ADDRESS:	461 E JOHNSTON AVE		TELEPHONE:	(951) 658-8875
CITY:	HEMET	STATE: CA	ZIP CODE:	92543
CAPACITY:	49	CENSUS: 38	DATE:	05/18/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Liliana Alvarez, Med Tech		TIME COMPLETED:	01:25 PM

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) Tricia Danielson arrived unannounced to the facility to conduct an annual inspection with emphasis on infection control. LPA met with Liliana Alvarez, Med Tech and explained the purpose of today's visit. During the inspection, LPA interviewed Alvarez regarding the facility's infection control measures and inspected the facility for regulatory compliance. LPA observed appropriate COVID postings at the front entry area of the facility, however there were none found elsewhere in the facility. LPA observed that the facility was not equipped with sufficient hand hygiene supplies, sufficient cleaning/disinfecting provisions, and a supply of Personal Protective Equipment (PPE). The facility has no Mitigation Plan Report on file with the Department, therefore there is no designated infection control lead person who can track all COVID-19 cases and/or suspected cases, nor is there any documentation that staff have been trained in the facility's infection control measures. The facility does not have a plan in place to follow Community Care Licensing Division guidelines for COVID-19 testing, isolation, and properly caring for clients with COVID-19 positive results and/or exposures, nor is there a plan in place to monitor residents regularly for any changes in condition and to subsequently notify the resident's physician and emergency personnel in the event the resident presents any COVID-19 symptoms. Each resident bathroom was also lacking a COVID hand washing poster. Upon entry to the facility, LPA was not screened for COVID symptoms, recent exposure to COVID, nor was a temperature taken. Additionally, there is no sign in out procedure in place for visitors to the facility. The following additional observations were made during the tour of the facility: the handrail at room #24 and #25 is broken as well at the main hallway corner in front of the calendar. Room #15 bathroom was missing a toilet paper holder and toilet tank lid. Bathroom #24 sink and toilet rim were filthy and the toilet paper holder and tile were missing. The window had a broken handle in bathroom #24. Room #24 was malodorous. The floor at the North exit was soiled with a dried liquid that smelled of urine. Bathroom #21 sink, toilet, floor, and shower were dirty. The shower floor in bathroom #21 was cracked and the door jamb near the shower is corroded. Additionally, there was no toilet paper in bathroom #21. Bathroom #20 was overwhelmingly (CONTINUED ON LIC 809C)

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022

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 45

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
	VISIT DATE: 05/18/2022

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
26
27
28
29
30
31
32

(CONTINUED FROM LIC809)
malodorous and a pile of soiled clothes were observed on the floor. The sink, toilet, and floor were filthy as well. Room #20 was very dirty and malodorous with piled trash, cookies, and empty drinking vessels on the floor.
Therefore, based on the observations made during today’s visit, the following deficiencies were cited per Title 22, Division 6 of the California Code of Regulations. See LIC 809D. An exit interview was conducted and this reported was provided along with appeal rights.

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022

LIC809 (FAS) - (06/04)

Page: 4 of 45

Document Has Been Signed on 05/18/2022 01:05 PM - 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: 05/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above in 5 out of 5 areas toured which poses a potential health, safety or personal rights risk to persons in care. Bathroom #15 was missing a toilet paper holder and toilet tank lid. Hallway handrails were broken in front of the calendar and rooms #24 and #25. Bathrooms #24, 21, and 20 contained dirty sinks, toilets, floors, and shower in bathroom #21. Bathroom #21 was missing toilet paper, the door jamb near the shower is corroded, and the shower floor is cracked. Rooms #24 and 20 were malodorous.
	POC Due Date: 05/31/2022
	Plan of Correction
1 2 3 4	The facility agreed to have all identified areas fixed and/or cleaned by POC due date 5/31/2022.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Deborah Mullen	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022

LIC809 (FAS) - (06/04)

Page: 39 of 45