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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 360900100
Report Date: 07/31/2023
Date Signed: 07/31/2023 03:49:39 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/01/2021 and conducted by Evaluator Tricia Danielson
COMPLAINT CONTROL NUMBER: 18-AS-20210301092629
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: 42DATE:
07/31/2023
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:LInda Woofter, Executive DirectorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff does not properly report incidents involving a resident
Staff denies a resident visitations
Staff denied a resident access to medical appointment
Staff did not properly supervise a resident while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to conclude an investigation into the allegation listed above. LPA met with Executive Director Linda Woofter and explained the purpose of the visit.
Regarding the allegation "Staff does not properly report incidents involving a resident", it was alleged that in February 2020, Resident #1 (R1) had been had been found outside of the facility in the morning time after being locked out all night. Two (2) of three (3) staff interviewed had no recollection of the incident. One (1) of three (3) staff interviewed indicated the incident did not occur. Interview with R1's responsible party revealed they had only been told of the incident through a former staff member and months after it occurred. However, a review of incident reports pertaining to R1 revealed on 2/28/2020, the supervision of R1 had been unverified. The incident report does not indicate any reports were made to R1's responsible party.
Regarding the allegation "Staff denies a resident visitations", it was alleged that R1 was denied visits from family after family failed to follow COVID visitation protocols. Interview with ED Woofter revealed R1's
(CONTINUED ON LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-8031
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2023
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 6
Control Number 18-AS-20210301092629
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: BRASWELLS YUCAIPA LEISURE MANOR
FACILITY NUMBER: 360900100
VISIT DATE: 07/31/2023
NARRATIVE
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(CONTINUED FROM LIC9099)
responsible party failed to adhere to COVID visitation protocols on several occasions even after repeated reminders. As a result, R1 was prohibited from physical in person visits from their responsible party. Interview with R1's responsible party revealed they were aware of the COVID visitation protocols but they did not care and did what they wanted anyway.
Regarding the allegation "Staff denied a resident access to medical appointment", it was alleged that ED Woofter did not permit R1 to attend a scheduled medical appointment accompanied by their family. Interview with ED Woofter confirmed the incident did occur as alleged. ED Woofter contended that R1's family were not medical professionals and therefore may not ensure proper COVID protocols would be implemented. As a result, ED Woofter did not permit R1 to leave the facility for the appointment and canceled the appointment.
Regarding the allegation "Staff did not properly supervise a resident while in care", it was alleged that on an unknown date, staff failed to complete a bed count which resulted in R1 being left outside overnight. Interview with ED Woofter indicated this incident had not occurred. However, a review of incident reports pertaining to R1 revealed on 2/28/2020, the supervision of R1 had been unverified. The incident report indicated Staff #1 (S1) was on duty at the time of the unverified supervision. S1's employed at the facility ceased in March 2020.
Based on LPA’s interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099 D. An exit interview was conducted and a copy of this report was provided along with Appeal Rights and LIC811- Confidential Names list.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-8031
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 18-AS-20210301092629
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: BRASWELLS YUCAIPA LEISURE MANOR
FACILITY NUMBER: 360900100
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/01/2023
Section Cited
CCR
87468.1
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Personal Rights of Residents in All Facilities-(a) Residents...shall have all of the following personal rights: (11) To have their visitors...permitted to visit privately during reasonable hours... provided... rights of other residents are not infringed upon. This requirement was not met as evidenced by:
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The licensee will submit a written statement of understanding of the regulation cited by POC due date.
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The licensee did not ensure the personal rights of all residents were maintained. Based on interviews conducted, ED prohibited in person visits for R1. This poses an immediate personal rights risk to residents in care
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CCR
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-8031
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 18-AS-20210301092629
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: BRASWELLS YUCAIPA LEISURE MANOR
FACILITY NUMBER: 360900100
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/01/2023
Section Cited
CCR
87468(a)(16)
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Personal Rights of Residents in All Facilities-(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(16)To receive or reject medical care or other services. This requirement was not met as evidenced by: The licensee did not ensure the personal
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The licensee will submit a written statement of understanding of the regulation cited by POC due date.
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rights of all residents were maintained. Based on interviews, ED confirmed she canceled R1's medical appointment because R1's family was going to accompany them to the appointment. This poses an immediate health, safety and personal rights risk to residents in care.
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Type B
08/11/2023
Section Cited
CCR
87211(a)(1)(D)
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Reporting Requirements- (a) Each licensee shall furnish...reports...including the following:(1)A written report shall be submitted...to the person responsible for the resident within 7 days of..occurrence of any...events specified...below. (D)...unexplained absence of any resident. This requirement was not
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The licensee will submit proof of staff training of the regulation cited by POC due date.
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met as evidence by: The licensee did not ensure R1's responsible party was notified of an unexplained absence. Based on interviews and records reviewed, ED denied R1 had an unexplained absence yet records reviewed indicated R1 may have been unaccounted for. This poses a potential
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(con't. from right) health, safety, and personal rights risks to residents in care.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-8031
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 18-AS-20210301092629
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: BRASWELLS YUCAIPA LEISURE MANOR
FACILITY NUMBER: 360900100
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/01/2023
Section Cited
CCR
87468.2(a)(
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Additional Personal Rights of Residents in Privately Operated Facilities- (a) In addition to...Section 87468.1... residents in...residential care facilities for the elderly shall have...the following personal rights:(4)To care, supervision...by staff ...to meet their needs. This requirement was not met as
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The licensee will submit proof of staff training of the regulation cited by POC due date.
*The due date is flexible to complete this training.
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evidenced by: The licensee did not ensure the personal rights of all residents were maintained. Based record review, the supervision of R1 had been unverified as reported in an incident reported dated 2/28/20. This poses an immediate health, safety, and personal rights risk to residents
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(con't. from left)
in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-8031
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/01/2021 and conducted by Evaluator Tricia Danielson
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210301092629

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: 42DATE:
07/31/2023
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:LInda Woofter, Executive DirectorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Resident is not being provided timely medical attention
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to conclude an investigation into the allegation listed above. LPA met with Executive Director Linda Woofter and explained the purpose of the visit.
Regarding the allegation "Resident is not being provided timely medical attention", it was alleged that R1 suffered a fall which resulted in a laceration to their hand however, staff did not seek medical attention and only taped the laceration. Review of R1's file indicated R1 had suffered a laceration to the back of the head during a fall on 10/13/2021 and received sutures and/or staples to close the wound in the local emergency room. Two (2) of two (2) staff interviewed reported emergency services were activated immediately following the fall. This agency has investigated the complaint alleging "Resident is not being provided timely medical attention". We have found that the complaint was unfounded, meaning that the allegation was 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 along with LIC811- Confidential Names list.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-8031
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 6