360900100-5-15-2023-56-AS-KCLS-CRYVJU-20230519162919

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 360900100
Report Date: 05/15/2023
Date Signed: 05/15/2023 11:29:34 AM

Substantiated

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
, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/10/2023 and conducted by Evaluator Bernadette Allen

COMPLAINT CONTROL NUMBER: 56-AS-20230510083500

FACILITY NAME:	BRASWELLS YUCAIPA LEISURE MANOR		FACILITY NUMBER:	360900100
ADMINISTRATOR:	LINDA WOOFTER		FACILITY TYPE:	740
ADDRESS:	32195 AVENUE E		TELEPHONE:	(909) 797-1314
CITY:	YUCAIPA	STATE: CA	ZIP CODE:	92399
CAPACITY:	61	CENSUS: 43	DATE:	05/15/2023
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Linda Woofter- Administrator		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff falsified medical documentation regarding resident in care.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to initiate and deliver the complaint investigation for the allegations above. LPA Allen met with Linda Woofter administrator who was informed of the purpose of the visit.
LPA Allen conducted interviews with (3) staff members, (1) outside party, and (1) Resident.

The interviews with the staff members said the facilities medical professional didn’t work on 2/7/2023. LPA reviewed the staff schedules for the month of February and the medical professional (staff member) was not scheduled to work on 2/7/2023. LPA also reviewed medical records for the clients in care and (R1) medical information was not provided at the time of visit. Staff 1 (S1) was interviewed, and they said that (R1) has refused to take a test therefore the medical document being requested could not be provided. During the visit (S1) was informed that documents were received that show that (R1) did have a medical test that was faulsified and that the document was not signed by their medical professional(staff member).

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette Allen	TELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023

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 3

Control Number 56-AS-20230510083500

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
, CA 92507

FACILITY NAME: BRASWELLS YUCAIPA LEISURE MANOR	FACILITY NUMBER: 360900100
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/15/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/19/2023 Section Cited CCR 87207	1 2 3 4 5 6 7	87207 False Claims No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.This requirement is not met as evidenced by:	1 2 3 4 5 6 7	POC- The licensee has agreed to provide training to all staff regarding the cited Regulation 87207 and Health and Safety codes. Licensee has agreed that they will provide a statement of understanding signed by all staff members confirming
	8 9 10 11 12 13 14	The licensee did not ensure that staff members understand that False Claims of any kind are not acceptable. The interviews conducted, and documents reviewed show that someone a (licensee, officer or employee of a licensee) falsified medical documents that were not signed by an licensed medical professional.	8 9 10 11 12 13 14	that they have read and understand the regulation 87207 and Health and Safety codes. Health and Safety codes NOTE: Authority cited: Section 1569.30, Health and Safety Code. Reference: Section 1569.44, Health and Safety Code. By the POC 5/19/2023.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette Allen	TELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 56-AS-20230510083500

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
, CA 92507

FACILITY NAME: BRASWELLS YUCAIPA LEISURE MANOR	FACILITY NUMBER: 360900100
	VISIT DATE: 05/15/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Resident 1 (R1) was interviewed and asked about taking a test from a medical professional and they said that they have refused to take any test because it is not required or needed. R1 said that the staff has asked her to take a test but she has refused several times.

Based on the evidence gathered during the investigation, the above allegation is found to be Substantiated. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

A deficiency is being cited on the attached LIC 9099-D.

LPA conducted an exit interview where this report was discussed with the Administrator Linda Woofter. A copy of this report was provided to the at the conclusion of this investigation with the Appeal Rights.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette Allen	TELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3