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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 03:36:34 PM

Unfounded


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
09/25/2020 and conducted by Evaluator Tricia Danielson
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200925094514
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
4
5
6
7
8
9
Questionable death
Facility staff did not follow resident's prescribed diet
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Tricia Danielson arrived to the facility to conclude a complaint investigation into the allegations listed above. LPA met with Christelle Bunney and discussed the purpose of the visit. Administrator Keely Miller was unavailble due to weather.
Regarding the allegation "Questionable death", it was alleged that Resident #1 (R1) was killed by the facility due to dehydration. Review of R1's death certificate revealed the immediate cause of R1's death was attributed to cardiac arrest with underlying causes attributed to respiratory arrest and chronic obstructive pulmonary disease. R1's death certifcate also lists hypertension, peripheral vascular disease, osteoporosis, depression, and glaucoma as significant conditions contributing to R1's death but not resulting in the underlying cause of death. There were no other causes of death listed.
Regarding the allegation "Facility staff did not follow resident's prescribed diet", it was alleged that R1 was not provided a diet suitable to their diabetic condition. Review of R1's hospice records as well as their physician's report revealed that R1 was prescribed a regular diet with no added sugar which concurs with information revealed during interview with R1's family that R1 received that same food as the other residents except
(CONTINUED ON LIC9099-C)
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: 1 of 4
Control Number 18-AS-20200925094514
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
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
(CONTINUED FROM LIC9099)
R1 received sugar free desserts. This agency has investigated the complaint alleging "Questionable death" and "Facility staff did not follow resident's prescribed diet". 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.
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: 2 of 4
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
09/25/2020 and conducted by Evaluator Tricia Danielson
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200925094514

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 staff did not respond to resident's call button in a timely manner
Facility staff did not provide an adequate quality of food.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Tricia Danielson arrived to the facility to conclude a complaint investigation into the allegations listed above. LPA met with Christelle Bunney and discussed the purpose of the visit. Administrator Keely Miller was unavailable due to weather.
Regarding the allegation "Facility staff did not respond to resident's call button in a timely manner", it was alleged that facility staff would place the call button out of the residents reach and would not respond to the call button if the resident was able to reach it. Interviews were conducted with eleven(11) residents. One(1) resident was an unreliable historian. Interviews revealed that four(4) of ten(10) residents reported staff do not respond to resident's call light in a timely manner. During tour of the facility, LPA observed call buttons within reach of those residents interviewed and who were not able to ambulate to the call button.
Regarding the allegation "Facility staff did not provide an adequate quality of food", it was alleged that Resident #1(R1) would often not eat the food because it was a poor quality. Interviews were conducted with eleven(11) residents. One(1) resident was an unreliable historian. Interivews revealed all eleven(11) residents reported the food was of an adequate quality. Although the allegations may have happened or (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: 3 of 4
Control Number 18-AS-20200925094514
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
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
(CONTINUED FROM LIC9099-A)
are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted and 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: 4 of 4