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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360900100
Report Date: 06/13/2023
Date Signed: 06/13/2023 01:29:36 PM


Document Has Been Signed on 06/13/2023 01:29 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:BRASWELLS YUCAIPA LEISURE MANORFACILITY NUMBER:
360900100
ADMINISTRATOR:LINDA WOOFTERFACILITY TYPE:
740
ADDRESS:32195 AVENUE ETELEPHONE:
(909) 797-1314
CITY:YUCAIPASTATE: CAZIP CODE:
92399
CAPACITY:61CENSUS: 43DATE:
06/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Linda Woofter, AdministratorTIME COMPLETED:
01:25 PM
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Licensing Program Analyst, Amber Coleman (LPA) arrived at the Braswells Yucaipa Manor unannounced to conduct an Annual Inspection. LPA introduced self and stated purpose of the visit. LPA was asked to sign in and met with Linda Woofter, Administrator. The current census is 43.

During the visit, LPA was provided a tour of the facility, reviewed both staff and resident files and utilized the CARE Tool. LPA observed the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting. LPA inspected resident bathrooms; bathrooms were clean and appliances were operating appropriately. The facility is equipped with operating smoke detectors and carbon monoxide alarms. The last fire drill was conducted by a company, Fire Drill Services on 6/8/23. Posters such as; the personal rights and disaster plans were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible in an unattached garage/shed. The designated storage space for client/staff files is the facility office, attached to the facility kitchen and Administrator office; which is kept secure. Medications were locked and inaccessible to residents. The facility had emergency, first aid kits, and Personal Protective Equipment readily available for residents in care. LPA observed Activity Calendars posted in public view in both the facility and the Memory Care Unit. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care.
Food Service: Non-perishable and perishable food supply is sufficient for number of clients residing in the facility. Facility has a variety of food available for clients. Dishes, cups, and utensils were also stored properly. Emergency food and water were also observed. Please see LIC809-C
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber ColemanTELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: BRASWELLS YUCAIPA LEISURE MANOR
FACILITY NUMBER: 360900100
VISIT DATE: 06/13/2023
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Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department.
Record Review: LPA reviewed resident files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. Medications were audited at random and appeared to be dispensed appropriately by staff members.

Based on observations, no deficiencies will be cited per Title 22, California Code of Regulations. A copy of this report was read/reviewed with Licensee; signature acknowledges understanding and receipt of report and attachments.

SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber ColemanTELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023
LIC809 (FAS) - (06/04)
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