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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336412146
Report Date: 12/12/2023
Date Signed: 01/19/2024 12:27:01 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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
10/21/2020 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20201021144409
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: 29DATE:
12/12/2023
UNANNOUNCEDTIME BEGAN:
08:27 AM
MET WITH:Andrea Scott, AdministratorTIME COMPLETED:
11:37 AM
ALLEGATION(S):
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9
Persons under 60 years of age, are incompatible with other residents retained at the facility
Licensee did not provide personal accommodations and services to residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facilty to deliver findings for the allegation(s) noted above. LPA met with Administrator Andrea Scott and explained the purpose of the visit, and the elements of the allegation(s). The allegation(s) were investigated, the investigation consisted of observations, interviews and records review

Reagrding the allegation persons under 60 years of age, are incompatible with other residents retained at the facility. The complaint was received on 10/21/20 alleging that the residents admitted to the facility were not compatible with other residents. LPA conducted a review of the facility’s resident roster that revealed that there are currently six (6) residents that are under the age of 59. A review of the resident’s file revealed that the residents had a preadmission appraisal conducted. A review of the facility’s unusual incident reports and staff interviews revealed that the residents are appropriate and there are not any significant concerns that would question their placement, as their needs are compatible with other residents in care. In addition, interviews further revealed that the residents require the same amount of care and supervision
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 18-AS-20201021144409
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 SENIOR LIVING
FACILITY NUMBER: 336412146
VISIT DATE: 12/12/2023
NARRATIVE
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as do the other residents in the facility. Based on records review and interviews the allegation is UNSUBSTANTIATED.

Licensee did not provide personal accommodations and services to residents.

On today’s date 12/12/23, LPA conducted a tour of the interior and exterior of the facility. LPA observed for the facility have a linen closet that had several new sheets/pillows case sets. LPA observed several new bath towels that were sufficient for the number of residents in care. LPA only observed two (2) bottles of body wash specifically for men and two (2) boxes of facial soap. LPA conducted interviews with residents which revealed that soap is always provided. LPA inquired as to why the supply was low. It was explained that due to the fire the hygiene products were lost due to the fire that the facility had in August 2023. Staff went to the store to purchase additional hygiene items, as well as washcloths as the residents only had hand towels.

In addition, the resident’s denied having used pieces of sheets to bathe with. Based on observations and interviews the allegation of licensee did not provide personal accommodations and services to residents is unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation(s) occurred.

An exit interview was conducted and a copy of this report was 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: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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
10/21/2020 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20201021144409

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: 29DATE:
12/12/2023
UNANNOUNCEDTIME BEGAN:
08:27 AM
MET WITH:Andrea Scott, AdministratorTIME COMPLETED:
11:37 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Insufficient staff to meet residents' needs
Facility does not have an administrator
INVESTIGATION FINDINGS:
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5
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9
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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facilty to deliver findings for the allegation(s) noted above. LPA met with Administrator Andrea Scott and explained the purpose of the visit, and the elements of the allegation(s). The allegation(s) were investigated, the investigation consisted of observations, interviews and records review.
Regarding the allegation of insufficient staff to meet resident's needs. The complaint was received on 10/21/20, a complaint visit was conducted on 10/29/20, at the time of the visit the facility had a census of 9. It was reported that Resident #1 (R1) had sustained a fall and required a 2 person assist, but there was only one staff available. LPA attempted to obtain R1's file, however was unsuccessful, as it was determined that R1 was not a resident at the facility but was a patient next door at the skilled nursing facility (SNF). LPA obtained a copy of the face sheet from the SNF and verified that R1 was in fact a patient at the the SNF on the following dates, 07/03/19-10/15/20. Based on interviews and records review the allegation of insufficient staff to meet resident's needs is UNFOUNDED.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 18-AS-20201021144409
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 SENIOR LIVING
FACILITY NUMBER: 336412146
VISIT DATE: 12/12/2023
NARRATIVE
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Facility does not have an administrator

The complaint was received on 10/21/20, and the Administrator at the time was Jamal Shalabi. LPA conducted a review of records and observed for the facility administrator to have a current administrator’s certificate that expired on 12/31/20. Based on records review the allegation of facility does not have an administrator is UNFOUNDED. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

An exit interview was conducted and a copy of this report was 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: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4