360900521-2-28-2023-18-AS-DMUN-CPJ7JW-20230301204302

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 360900521
Report Date: 02/28/2023
Date Signed: 02/28/2023 04:19:03 PM

Unsubstantiated

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
11/10/2020 and conducted by Evaluator Tricia Danielson

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20201110092924

FACILITY NAME:	BRASWELL'S MEDITERRANEAN GARDENS		FACILITY NUMBER:	360900521
ADMINISTRATOR:	KEELY MILLER		FACILITY TYPE:	740
ADDRESS:	12295 4TH STREET		TELEPHONE:	(909) 797-1131
CITY:	YUCAIPA	STATE: CA	ZIP CODE:	92399
CAPACITY:	130	CENSUS: 71	DATE:	02/28/2023
		UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Christelle Bunney, Receptionist		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Resident sustained an injury while in care

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 "Resident sustained an injury while in care", it was alleged that Resident #1(R1) was unsupervised causing them to trip over a sprinkler and knock out their first row of teeth. Records reviewed did not indicate R1 required constant direct supervision. Review of R1's Physician's Report revealed they are able to leave the facility unassisted and did not have wandering behavior. Review of R1's Appraisal/Needs and Services Plan revealed R1 liked to walk around the parking lot area of the facility for exercise. Interviews conducted with facility staff revealed R1 routinely walked the property for exercise and this incident occurred in the front of the facility in a grassy area where R1 did not frequent. R1 was unable to be interviewed.
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.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 248-8031
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (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)

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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
11/10/2020 and conducted by Evaluator Tricia Danielson

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20201110092924

FACILITY NAME:	BRASWELL'S MEDITERRANEAN GARDENS		FACILITY NUMBER:	360900521
ADMINISTRATOR:	KEELY MILLER		FACILITY TYPE:	740
ADDRESS:	12295 4TH STREET		TELEPHONE:	(909) 797-1131
CITY:	YUCAIPA	STATE: CA	ZIP CODE:	92399
CAPACITY:	130	CENSUS:	DATE:	02/28/2023
		UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Christelle Bunney, Receptionist		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Staff failed to seek medical attention for resident in a timely manner
Staff failed to report an incident

INVESTIGATION FINDINGS:

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Licensing Program Analyst(LPA) Tricia Danielson arrived unannounced to the facility to conclude an investigation into the allegations listed above. LPA met with Receptionist Christelle Bunney and explained the purpose of the interview. Administrator Keely Miller was unavailable due to weather.
Regarding the allegation "Staff failed to seek medical attention for resident in a timely manner", it was alleged that R1 was not examined by a doctor following a fall at the facility on 11/7/2020 which resulted in broken teeth. Interviews conducted revealed R1 was not examined by a doctor following the fall and it was not until R1 complained of a headache on 11/9/2020 that the facility sent R1 to a hospital for examination but only after being asked to do so by R1's Conservator.
Regarding the allegation "Staff failed to report an incident", it was alleged that the facility failed to notify R1's Conservator of their fall on 11/7/2020. Interview conducted with the med tech on duty at the time of the incident revealed he could not recall if notification was made to R1's Conservator. Interview with Miller revealed the facility notified R1's foster mother not their Conservator. Review of R1's Appraisal/Needs and Services Plan revealed the facility was to notify R1's Conservator or doctor of any concerns related to R1.
(CONTINUED ON LIC9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 248-8031
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (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 4

Control Number 18-AS-20201110092924

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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(CONTINUATION FROM LIC9099-A)
Based on LPA’s interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations (Title 22, Division 6, Chapter 8), are 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.

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 248-8031
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (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 4

Control Number 18-AS-20201110092924

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 A 03/01/2023 Section Cited CCR 87465(a)(1)	1 2 3 4 5 6 7	Incidental Medical and Dental Care- (a) A plan for incidental medical and dental care shall be developed... The plan shall ...provide for assistance...with the following:(1)The licensee shall arrange...for medical care... appropriate to the conditions and needs of residents. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The licensee will conduct training with all staff regarding the requirement for the arrangement of a medical evaluation following a threat to the health and/or safey to any resident. Proof of training to be submitted to CCL by 5PM 3/1/2023.
	8 9 10 11 12 13 14	The licensee did not ensure medical care was arranged for the needs of R1. Based on interviews conducted, provisions for medical care were not made for R1 following their fall on 11/7/2020. The facility only made arrangements for such care two days later after being instructed to do so by R1's Conservator. This poses an immediate health,	8 9 10 11 12 13 14	(continued from left) safety, and personal rights risk to residents in care.
Type B 03/10/2023 Section Cited CCR 87211(a)(1)(D)	1 2 3 4 5 6 7	Reporting Requirements- (a) Each licensee shall furnish...reports...including ...the following:(1)A written report shall be submitted to the licensing agency and to the person responsible for the resident... of the occurrence of...(D) Any incident which threatens the welfare, safety or health...of any resident. This requirement was not met	1 2 3 4 5 6 7	The licensee will conduct training with all staff regarding the requirement for all incidents to be reported in writing to CCL as well as the resident's responsible party following any incident which threatens the health and/or safety of any resident. Proof of training to be submitted to CCL by 5PM 3/10/2023.
	8 9 10 11 12 13 14	as evidenced by: The licensee did not ensure a written report was submitted to R1's Conservator. Based on interviews conducted, the facility notified R1's foster mother of R1's fall but not their Conservator. This poses a potential health, safety, and personal rights risk to residents in care.	8 9 10 11 12 13 14

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 Mullen	TELEPHONE: (951) 248-8031
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (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)

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