360900521-7-19-2021-18-AS-EMAN-C5QQBD-20210809120122

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 360900521
Report Date: 07/19/2021
Date Signed: 07/19/2021 03:11:37 PM

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
05/20/2020 and conducted by Evaluator Natalie Gayoso

COMPLAINT CONTROL NUMBER: 18-AS-20200520091757

FACILITY NAME:	BRASWELL'S MEDITERRANEAN GARDENS		FACILITY NUMBER:	360900521
ADMINISTRATOR:	VIRGINIA BAUER		FACILITY TYPE:	740
ADDRESS:	12295 4TH STREET		TELEPHONE:	(909) 797-1131
CITY:	YUCAIPA	STATE: CA	ZIP CODE:	92399
CAPACITY:	130	CENSUS: 71	DATE:	07/19/2021
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Keely Miller		TIME COMPLETED:	03:16 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident sustained injury while in care.
Staff failed to ensure resident received timely medical attention.

INVESTIGATION FINDINGS:

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

Licensing Program Analysts (LPAs) Natalie Gayoso and Anna Bueno conducted an unannounced visit for the purpose of following up on a complaint investigation and deliver finidings. LPAs met with Administrator Keely Miller and explain the purpose of today's visit. The investigation consisted of interviews with pertient parties and file review.

The first allegation indicates resident sustained injury while in care. Interviews with staff revealed that Resident #1 (R1) had an unwitnessed fall that resulted in R1 sustaining a swollen left eye. LPAs reviewed Special Incident Report (SIR) that was submitted to the Department. SIR stated resident fell off toilet face forward causing big knot on left eye. Per physician's report R1 is ambulatory, needs assistance with medication management, but does not need assistance with daily living (ADLs).

The second allegation indicates staff failed to ensure resident received timely medical attention. Interviews with staff revealed that when R1 fell and sustained a knot on left eye, facility assess R1 and attempted to

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Natalie Gayoso	TELEPHONE: (951) 290-1102
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2021

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 2

Control Number 18-AS-20200520091757

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: BRASWELL'S MEDITERRANEAN GARDENS	FACILITY NUMBER: 360900521
	VISIT DATE: 07/19/2021

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

seek medical attention, but R1 refused. SIR submitted to the Department also states R1 refused medical attention but was assessed by staff, given an ice pack and Naproxen for pain, and R1's doctor was notified. Interview with Witness #1 (W1) stated that R1 refused medical attention and said they were ok. W1 stated they had to convince R1 to seek medical attention to make sure there were no fractures or possible concussion due to fall and bruising of eye.

Based on interviews and file review, the allegations are UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

No deficiencies were cited during this visit.
An exit interview was conducted, and a copy of this report was provided to the Administrator.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Natalie Gayoso	TELEPHONE: (951) 290-1102
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 2