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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336412146
Report Date: 11/12/2020
Date Signed: 11/12/2020 02:58:15 PM

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 SENIOR LIVINGFACILITY NUMBER:
336412146
ADMINISTRATOR:JOHANNA LAGANDAONFACILITY TYPE:
740
ADDRESS:461 E JOHNSTON AVETELEPHONE:
(951) 658-6374
CITY:HEMETSTATE: CAZIP CODE:
92543
CAPACITY:49CENSUS: 9DATE:
11/12/2020
TYPE OF VISIT:Case Management - Legal/Non-complianceANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Administrator, Johanna LagandaonTIME COMPLETED:
02:35 PM
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On 11/12/20 an announced tele conference call was made to facility. The purpose was address non-compliance issues with facility representatives. Attendees for facility were Administrator, Johanna Lagandaon and prospective licensee and property owners: Abraham Chamede and Mario Marasigan. Representatives for Community Care Licensing present were Licensing Program Manager (LPM), Joel Esquivel and Licensing Program Analyst (LPA), David Cuevas. During teleconference, the following where the topics reviewed during today’s tele conference:

· Resident Intakes for Placement: It was reported that facility is placing residents who are below approved age group.

· Change of Ownership: Identify new ownership, submission of application dates, and current status of application. Known as: Meadowbrook Assisted Living, LLC # 331881058.

Issues of noncompliance were identified and communicated to facility representatives. An action plan was requested from facility representatives to ensure compliance is maintained regarding residents’ intakes and proper change of ownership protocols. Current administrator Johanna Lagandaon is the designated responsibility party to oversee facility. As such operational decisions and placement decisions are her responsibility.

The regional office will follow up with CAB to identify where in the process the application is currently. LPA will continue to monitor the facility during this transition period.

An exit interview was conducted and a copy will be provided via email with facility representative signature requested.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: David CuevasTELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2020
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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