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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 360900521
Report Date: 12/28/2022
Date Signed: 12/28/2022 04:20:07 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, 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
12/22/2022 and conducted by Evaluator Bernadette Allen
COMPLAINT CONTROL NUMBER: 56-AS-20221222140837
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: 72DATE:
12/28/2022
UNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Keely Miller AdministratorTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Resident fell multiple times sustaining injuries
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Bernadette Allen made an unannounced visit to the facility for the purpose of initiating and delivering findings on the complaints above. LPA met with Keely Administrator who was informed of the purpose of my visit and the allegation above.

Allegation #1 -Resident fell multiple times sustaining injuries
LPA interview three (3) staff members who confirmed that resident 1 (R1) has fallen several times which has caused scars to (R1) legs and forehead. Based on record review and observations during LPA visit the resident has falling several times and sustained injuries while in care. Based on observation and record review as to allegation that the resident has fell multiple times and sustained injury is 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.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette AllenTELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2022
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 56-AS-20221222140837
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: BRASWELL'S MEDITERRANEAN GARDENS
FACILITY NUMBER: 360900521
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/24/2023
Section Cited
CCR
87466
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Observation of the Resident
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight...
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*The is an amended document originally delivered on 12/28/2022*
The licensee will provide traing to all direct care staff members on regulation cited 87466. The licensee will also have the resident (R1) reassessed by a physician to determine if a fall plan care plan is needed.
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This requirement is not met as evidenced by: The licensee didn't ensure staff had proper training on observation of residents in care.
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If a it is determined that addititional care is needed per the phycians orders a copy of the new appraisal/needs and service plan will need to be forward to LPA Allen. 4/1/2023.

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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: 12/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2022
LIC9099 (FAS) - (06/04)
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