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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 360900521
Report Date: 02/28/2023
Date Signed: 02/28/2023 03:53:53 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
10/08/2020 and conducted by Evaluator Tricia Danielson
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20201008162354
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: 71DATE:
02/28/2023
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Christelle Bunney, ReceptionistTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Facility did not adhere to admission agreement
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 Christelle Bunney and explained the purpose of the visit. Administrator Keely Miller was unavailable due to weather.
Regarding the allegation "Facility did not adhere to admission agreement", it was alleged that Resident #1(R1) was not receiving assistance with showers as indicated in their admission agreement. Interview with AD Miller indicated R1 was an independent resident and was not entitled to assistance with showers, but did receive assistance if staff had availability. Miller also indicated R1 was not charged for this service and came to expect it. Review of R1's Physician's Report revealed R1 had mild cognitive impairment, lacked the capacity to bathe theirself, and was unable to manage medications. R1's Appraisal/Needs and Services Plan also revealed R1 was to received shower assistance twice weekly. Review of R1's Admission Agreement revealed R1 paid a single monthly fee which included assistance with activities of daily living(ADLs) including bathing.
(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: 02/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2023
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-20201008162354
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: BRASWELL'S MEDITERRANEAN GARDENS
FACILITY NUMBER: 360900521
VISIT DATE: 02/28/2023
NARRATIVE
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(CONTINUED FROM LIC9099)
Based on LPA’s interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), is 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: 02/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 18-AS-20201008162354
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: BRASWELL'S MEDITERRANEAN GARDENS
FACILITY NUMBER: 360900521
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/10/2023
Section Cited
CCR
87507(f)
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Admission Agreements- (f)The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement was not met as evidenced by: The licensee did not comply with the terms in R1's admission agreement.
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The licensee will conduct training with all staff regarding the required services to be provided in each resident's admission agreement. Proof of training to be submitted to CCL by 5PM 3/10/2023.
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R1's admission agreement indicated R1 paid a monthly fee to be provided assistance with ADLs which included bathing. Interview with AD revealed AD believed bathing assistance for R1 was not required, therefore would only get it when time permitted and free of charge. This poses a potential health, safety and personal rights 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: Deborah MullenTELEPHONE: (951) 248-8031
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2023
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
10/08/2020 and conducted by Evaluator Tricia Danielson
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20201008162354

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: 71DATE:
02/28/2023
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Christelle Bunney, ReceptionistTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
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5
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9
Facility is making false claims
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 Receptionist Christelle Bunney and explained the purpose of the visit. Administrator Keely Miller was unavailable due to weather.
Regarding the allegation, "Facility is making false claims", it was alleged that AD Miller directed Staff #1(S1) to back date six weeks worth of shower logs for R1 and have R1 sign the logs to indicate shower assistance had been provided even though it had not. LPA was unable to review the shower logs in question due to the fact that those records were not kept following their completion as the facility is not required to. Interview with AD Miller revealed no staff was given this directive, all staff receive a code of conduct training at the time of their hire and no staff would do such a thing. Review of the facility's code of conduct revealed covered topics such as falsification of company records or providing information that is known to be false or misleading. Interviews conducted with six(6) of six(6)staff indicated they received a code of conduct upon hire and five(5) of six(6) staff interviewed were not asked by AD Miller to falsify facility documentation. Review of the facility's employee roster revealed no staff member of the name S1 was or has ever been employed at the facility however, (CONTINUED ON LIC9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-8031
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 18-AS-20201008162354
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: BRASWELL'S MEDITERRANEAN GARDENS
FACILITY NUMBER: 360900521
VISIT DATE: 02/28/2023
NARRATIVE
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(CONTINUED FROM LIC9099-C)
Staff#2(S2) was identified through the investigation to be the staff in question and has the same first name and similar last name as S1. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted and a copy of this report was provided along with LIC811- Confidential Names list.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-8031
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2023
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,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/08/2020 and conducted by Evaluator Tricia Danielson
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20201008162354

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: DATE:
02/28/2023
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Christelle Bunney, ReceptionistTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is not following physician's orders
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst(LPA) Tricia Danielson arrived unannounced to the facility to conclude an investigation into the allegation listed above. LPA met with Christelle Bunney and explained the purpose of the visit. Administrator Keely Miller was unavailable due to weather.
During today's visit, LPA reviewed and obtained copies of pertinent documents, interviewed one(1) resident and one(1) staff. Regarding the allegation "Facility is not following physician's orders", it was alleged Resident #2(R2) was not being accommodated a special diet. Review of the facility's Admission Agreement revealed "basic meal services- that includes three(3) meals per day including physician prescribed, medically necessary diets". However, review of R2's Physician's Report revealed a special diet was not indicated. Review of R2's Appraisal/Needs and Services Plan revealed R2 was to be encouraged to follow a low sodium diet. Interview with R2 revealed they have not been prescribed a specific diet to follow by a physician.
This agency has investigated the complaint alleging "Facility is not following physician's orders". 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: 02/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2023
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