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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881631
Report Date: 11/20/2024
Date Signed: 11/20/2024 11:21:41 AM

Document Has Been Signed on 11/20/2024 11:21 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 PLACE ASSISTED LIVINGFACILITY NUMBER:
331881631
ADMINISTRATOR/
DIRECTOR:		MARTINEZ, EILEENFACILITY TYPE:
740
ADDRESS:461 E JOHNSTON AVENUETELEPHONE:
(818) 470-6457
CITY:HEMETSTATE: CAZIP CODE:
92543
CAPACITY: 49CENSUS: 0DATE:
11/20/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Andrea ScottTIME VISIT/
INSPECTION COMPLETED:
11:35 AM
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Licensing Program Analyst (LPA),Abdoulaye Zerbo conducted an announced pre-licensing inspection at the facility and met with Administrator Andrea Scott

Application: The inspection is for a Change of Ownership for a Residential Care Facility for Elderly (RCFE) application. The Riverside County Fire Department approved a fire clearance on 08-09-2024 for forty nine (49) non-ambulatory clients among which, twenty (20) can be Bedridden .

Buildings and Grounds: The facility is composed of three (3) buildings. Building one(1) consist of eight (8) bedrooms, 5 bathrooms, a kitchen area and one (1) staff room. Building two (2) consist of fifteen (15) bedrooms with ten(10) bathrooms, a kitchen area, an activity room and one (1) staff room. Building one (3) has 3 bedrooms two (2)bathrooms and a kitchen area, but LPA was unable to visit the building because the fire department and the city have secured the area and restricted access to it due to a fire that occurred on August 20, 2023. Water temperature was measured at different locations, averaging 105.7 F. The interior and exterior walkways of the facility were observed to be clutter free with no obstructions present. Smoke and Carbon Monoxide detectors are hard wired in working order. There is no gated pool and there are no weapons stored in the facility. Client bedrooms are fully furnished, and privacy is available. Outdoor areas have sufficient room for activities and leisure. Laundry will be done by a laundry service every Friday.

Storage and Supplies: Medications and residents files will be stored in a locked cabinet in the staff room in building two(2), inaccessible to any unauthorized individuals. Secured locked cabinets in the staff room in building one (1) are available for staff files. A complete first aid kit was observed to be available. Cleaning supplies will be stored in a secured location in the kitchen area. Linens, and equipment appeared to be in good repair and sufficient for the approved census. Fire extinguishers were available and fully charged with an expiration date of May 28,2025.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE: DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 PLACE ASSISTED LIVING
FACILITY NUMBER: 331881631
VISIT DATE: 11/20/2024
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Food Service: Utensils and dishware are sufficient for the requested capacity. The refrigerator and freezer are in working order. Sharps knives will be stored in a locked pantry in the kitchen area, available only to authorized individuals.

Forms: The following signs were observed to be posted at the facility: Personal Rights, Complaint information, Emergency disaster plan, the facility sketch, ombudsman poster. LPA verified the Administrator's Certification, with an expiration date of November 14, 2025 and CPR certification with the expiration date of November 20, 2026

LPA observed that the physical plant is clean, in good repair, and to be hazard-free during today’s visit. The applicant has completed COMP III orientation on 11-20-2024. LPA determined the facility meets the operational requirements for licensure. The Pre-licensing inspection is complete and has satisfied all requirements in accordance with Title 22, California Code of Regulations. An exit interview was conducted, and this report was discussed and provided to Administrator Andrea Scott.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
LIC809 (FAS) - (06/04)
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