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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603081
Report Date: 11/07/2023
Date Signed: 11/07/2023 11:09:40 AM


Document Has Been Signed on 11/07/2023 11:09 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:MEADOWBROOK VILLAGE CHRISTIAN RETIREMENT COMMUNITYFACILITY NUMBER:
374603081
ADMINISTRATOR:MARK MEMMELAARFACILITY TYPE:
741
ADDRESS:100 HOLLAND GLENTELEPHONE:
(760) 746-2500
CITY:ESCONDIDOSTATE: CAZIP CODE:
92026
CAPACITY:200CENSUS: 260DATE:
11/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:38 AM
MET WITH:ASSISTED LIVING DIRECTOR, BARBARA DOSSTIME COMPLETED:
11:08 AM
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On November 07, 2023, Licensing Program Analyst (LPA), Venus Mixson made an unannounced visit to the facility to conduct an annual licensing inspection, and met with the Assisted Living Director, Barbara Doss. The LPA introduced herself and stated the purpose of the visit.

LPA Mixson toured the facility along with the Assisted Living Director, and inspected the facility inside and outside, and there were no obstructions to the indoor or outdoor passageways at the time of this visit. The facility is licensed to serve elderly residents; ages 60 and above; all of whom may be non-ambulatory and ambulatory, currently there are 30 residents and 20 staff currently for assisted living. The facility has an approved hospice waiver for a number of residents to include five. The facility is approved for delayed egress in memory care, and the LPA observed a sampling of the living units.
Physical Plant: The facility phone number is (760)746-2500, and is operable. The LPA observed a sample of the resident living units, and they are equipped with required furniture as per Title 22. The LPA inspected the facility restrooms, and the hot water temperature tested within regulations. The restrooms were clean and appliances were operating appropriately at the time of this visit. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and fire extinguishers. The LPA observed required postings such as; the Ombudsman poster, "If you See Something, Say Something" and the "Personal Rights" postings were posted in a common area. The cleaning supplies and sharp items were kept locked and inaccessible to the residents. There was a designated office for the resident and staff files. Medications: were locked and inaccessible to residents. The overall facility is clean, welcoming, and the furniture is in good condition. The facility air conditioning and other appliances were operable currently at the time of this visit. Food Service: A menu was observed, along with non-perishable and perishable foods. The food supply is sufficient per regulations, and there are a variety of food types available for residents. The facility does not serve breakfast at all, but provides noon meal and evening meals. Care & Supervision The facility has sufficient staff, several caregivers were observed at the time of this visit, and staff were assisting the residents with crafts and arts activity. Records Review: The LPA reviewed six resident files, six staff files, and reviewed previous CCL reports. There were no Title 22, Division 6 Regulation violations observed and/or cited during todays visit.
An exit interview was conducted and a copy of this report was given to the Assisted Living Director, Barbara Doss.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2023
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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