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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336412146
Report Date: 01/19/2024
Date Signed: 01/19/2024 12:30:40 PM


Document Has Been Signed on 01/19/2024 12:30 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
RIVERSIDE ASC, 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:0CENSUS: 0DATE:
01/19/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:22 AM
MET WITH:Andrea Scott, AdministratorTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Javina George conducted a collateral visit to the Meadowbrook Health Care Center-Skilled Nursing Facility (SNF), as well as to deliver amended findings and to obtain documentation related to complaint control number 18-AS-20201021144409.

LPA met with Andrea Scott, Administrator and informed her of the purpose of the visit.


An exit interview was conducted and a copy of this report was reviewed and provided to Andrea Scott, Administrator.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2024
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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