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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 360900100
Report Date: 07/20/2021
Date Signed: 09/23/2021 09:39:00 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
04/23/2020 and conducted by Evaluator Stephanie Williams
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200423084429
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: 48DATE:
07/20/2021
UNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Linda WoofterTIME COMPLETED:
12:20 PM
ALLEGATION(S):
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Staff are not adequately trained
Staff mismanaged residents medication
Staff do not provide adequate food service to residents
Staff do not provide resident with a comfortable environment
Facility is in disrepair
Staff did not report a change in resident's condition
Staff did not adequately care for a resident's catheter

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Stephanie Williams conducted an unannounced visit to the facility in order to deliver findings for the above allegations. LPA met with Administrator, Linda Woofter, and explained the purpose of today's visit. The investigation consisted of records review, direct observations, and interviews with staff and residents.

In regards to allegation #1, LPA interviewed Staff #1 (S1), Staff #2 (S2), and Staff #3 (S3) who all stated that facility staff have received proper training. S1 stated that the facility recently switched to online training, which is to be conducted by staff as soon as they are hired and annually thereafter. S1 also stated that facility staff also receive hands-on and shadow training. LPA reviewed documentation of staff training.

In regards to allegation #2, LPA interviewed S1, S2, and S3 who all denied that staff mismanage resident medications. S2 denied that Resident #1 (R1) has been given an incorrect dosage of medications. S2 stated
that R1 is very much aware of how R1's medications should be administered. LPA interviewed R1 who
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie WilliamsTELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021
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-20200423084429
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: BRASWELLS YUCAIPA LEISURE MANOR
FACILITY NUMBER: 360900100
VISIT DATE: 07/20/2021
NARRATIVE
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denied receiving an incorrect dosage of medications. R1 and Resident #2 (R2) stated that they are both getting all of their medications on time. R1, R2, and Resident #3 (R3) denied ever feeling over-medicated. LPA reviewed the facility's Medication Administration Record (MAR) in which it appeared that staff are administering medications appropriately.

In regards to allegation #3, LPA interviewed R1, R2, and R3 who all stated that they receive three meals a day plus snacks in between meals. R1, R2, and R3 stated that they believe the meals provided are nutritious. LPA interviewed S1, S2, and S3 who all stated that all special diets and alternative food requests are accommodated. LPA observed that residents were eating a nutritious and sufficient portion of food at the time of visit. LPA also reviewed the facility's food menu in which it appeared that the facility was providing adequate food service for residents in care.

In regards to allegation #4, LPA interviewed R1, R2, and R3 who stated that their rooms are comfortable. LPA conducted a walk-through of several rooms and buildings of the facility and observed that the room temperature was set between 74 degrees F and 75 degrees F.

In regards to allegation #5, LPA interviewed S1 who stated that some time around Spring 2020, a water pipe had busted underneath a bathroom tub, which affected two rooms. S1 stated that the facility did have running water; however, the two rooms that were affected by the water pipe bursting did not have hot water According to S1 and S2, the residents in those two rooms had access to hot water in another bathroom down the hall. LPA tested the hot water in affected rooms in which it appeared hot water was being dispensed through the sink faucet.

In regards to allegation #6, LPA interviewed S1, S2, and S3 who stated that all changes of condition are reported to appropriate persons. S1 and S2 both stated that the facility does not have an Independent Living building, only Assisted Living and Memory Care. S2 stated that Resident #4 (R4) did have a change in condition; however, R4 was immediately placed in a skilled nursing facility.

In regards to allegation #7, LPA interviewed S2 and S3 who stated that hospice agencies do provide training for catheter care. S2 and S3 stated that facility staff only empty catheter bags; however, the resident's hospice agency will provide the rest of the care for a resident's catheter. S1 and S3 denied that staff did not
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie WilliamsTELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 18-AS-20200423084429
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: BRASWELLS YUCAIPA LEISURE MANOR
FACILITY NUMBER: 360900100
VISIT DATE: 07/20/2021
NARRATIVE
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adequately care for a resident's catheter.

Based on evidence/record review/ interviews obtained during today’s visit, LPA has determined that the above allegation is UNSUBSTANTIATED; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted where this report (LIC 9099) was discussed and a copy was provided to the Administrator.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie WilliamsTELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021
LIC9099 (FAS) - (06/04)
Page: 3 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, 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
04/23/2020 and conducted by Evaluator Stephanie Williams
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200423084429

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: 48DATE:
07/20/2021
UNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Linda WoofterTIME COMPLETED:
12:20 PM
ALLEGATION(S):
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Lack of supervision of resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Stephanie Williams conducted an unnanounced visit to the facility in order to deliver findings for the above allegations. LPA met with Administrator, Linda Woofter, and explained the purpose of today's visit. The investigation consisted of records review, direct observations, and interviews with staff and residents.

LPA interviewed Staff #1 (S1) who stated that Staff #2 (S2) was terminated after learning that Resident #1 (R1) was left outside unsupervised for an unknown amount of time. According to S1 and Staff #3 (S3), this incident occurred around evening time in the memory care side of the facility where the doors are locked from the outside. S1 and S2 both stated that S2 verbally asked R1 to come inside but did not redirect R1. S1 stated that the facility's policy is to have constant supervision of the resident while he/she is outside or have a staff member outside with the resident.

Based on the evidence gathered during the investigation, the above allegation is SUBSTANTIATED. A finding
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie WilliamsTELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 18-AS-20200423084429
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: BRASWELLS YUCAIPA LEISURE MANOR
FACILITY NUMBER: 360900100
VISIT DATE: 07/20/2021
NARRATIVE
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that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted where this report (LIC 9099A) was discussed and a copy was provided to the Administrator.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie WilliamsTELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 18-AS-20200423084429
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BRASWELLS YUCAIPA LEISURE MANOR
FACILITY NUMBER: 360900100
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/27/2021
Section Cited
CCR
87411(d)(3)
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87411 Personnel Requirements - General (d) All personnel shall be given on the job training or have related experience in the ... (3) Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents. This requirement is not met as evidenced by:
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The Administrator agreed to conduct training on regulation 87411 and send proof of training (roster with date and names) to the Department by POC date of 7/27/2021.
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Based on interviews with S1 & S3, the licensee did not ensure that R1 was provided adequate supervision. This is a potential health and safety risk to residents 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: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie WilliamsTELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 6