331881058-5-23-2022-18-AS-EMAN-CFVUKT-20220630153939

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331881058
Report Date: 05/23/2022
Date Signed: 05/23/2022 03:20:01 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
05/20/2021 and conducted by Evaluator Jennifer Semin

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210520170634

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:	05/23/2022
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Ebreheem Hamed		TIME COMPLETED:	03:35 PM

ALLEGATION(S):

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Staff stole resident's personal belongings.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jennifer Semin conducted an unannounced visit to deliver the finding for the above complaint allegation. LPA met with administrator Ebraheem Hamed.
The investigation consisted of interviews with staff. Regarding the allegation, Staff stole resident's personal belongings. Staff denied stealing residents personal belongings. Staff stated they never had possession of R1’s identification card. R1 resided at the facility from March 2021 – May 2021 and they had their identification card in their possession. Staff stated R1 had their Identification card (ID) as they received a social security check which requires an ID to obtain. Staff admitted that all documents for Resident 1 (R1) were not maintained at the facility. LPA was unable to review any documents for R1. Facility was cited on 5/24/2021 for not maintaining this resident's file after they were discharged
Based upon interviews and due to the absence of maintained documentation, and although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED at this time.
An exit interview was conducted where this report was discussed and provided to Mr. Hamed.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Jennifer Semin	TELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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