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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360900521
Report Date: 11/14/2022
Date Signed: 11/16/2022 09:15:49 AM


Document Has Been Signed on 11/16/2022 09:15 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507



FACILITY NAME:BRASWELL'S MEDITERRANEAN GARDENSFACILITY NUMBER:
360900521
ADMINISTRATOR:KEELY MILLERFACILITY TYPE:
740
ADDRESS:12295 4TH STREETTELEPHONE:
(909) 797-1131
CITY:YUCAIPASTATE: CAZIP CODE:
92399
CAPACITY:130CENSUS: 74DATE:
11/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Keely Miller TIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to the facility to conduct a required annual inspection, with an emphasis on infection control, due to the COVID-19 pandemic. LPA Bernadette Allen identified herself to Administrator, Keely Miller who was informed of the purpose of the visit.

LPA Allen observed appropriate postings in the facility, including personal rights and visitation policies, which were in accordance with the department's guidelines. LPA Allen observed that the facility was also equipped with sufficient hand hygiene supplies, sufficient cleaning/disinfecting provisions, and a supply of Personal Protective Equipment (PPE). LPA Allen observed that the facility staff were wearing face coverings.

The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases and that staff are trained in the facility's infection control measures. The facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolation, and properly caring for clients with COVID-19 positive results and/or exposures. The facility also has a plan in place to monitor residents regularly for any changes in condition and to subsequently notify the resident's physician and emergency personnel in the event the resident presents any COVID-19 symptoms.

LPA Allen observed that the facility appeared to be meeting operational requirements. LPA Allen observed that all utilities and appliances were functioning properly, and all passageways clear of obstruction, including emergency exits.

The facility was equipped with sufficient food supply and emergency supplies. All inspected areas of the facility appeared clean and in good repair. LPA Allen observed that (S1) and (S2) did not have criminal record clearance/association with facility this poses an immediate health and safety risk to those in care a civil penalty has been assessed for a maximum of 5-days. A civil penalty of $1,000.00 was assessed on 11/14/2022.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette AllenTELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 11/16/2022 09:15 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: BRASWELL'S MEDITERRANEAN GARDENS
FACILITY NUMBER: 360900521

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
87355(e)(1)


This requirement is not met as evidenced by:
Deficient Practice Statement
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(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
Based on interview and record review, the licensee did not comply with the section cited above as LPA confirmed on Guardian that Staff 1 and Staff 2 did not have criminal clearance to work at the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/15/2022
Plan of Correction
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Licensee shall submit a Criminal Record Clearance to Community Care Licensing for Staff 1 and Staff 2 by the Plan of Correction (POC) date of 11/15/2022. Proof of submission to be submitted to LPA Allen by end of POC day.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette AllenTELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: BRASWELL'S MEDITERRANEAN GARDENS
FACILITY NUMBER: 360900521
VISIT DATE: 11/14/2022
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An exit interview was conducted where this report, LIC 809, LIC809-D, LIC421BG and , appeal rights were discussed and provided to Keely Miller.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette AllenTELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3