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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360900521
Report Date: 03/03/2023
Date Signed: 03/03/2023 02:06:19 PM


Document Has Been Signed on 03/03/2023 02:06 PM - 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,
, CA



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:
03/03/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Christelle Bunney, ReceptionistTIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to conduct a case management visit to address a deficiency observed during the investigation of complaint control number 18-AS-20210121081555.
During a facility visit on 2/28/2023, while waiting to interview Staff #1 (S1) who was in room 60 assisting two (2) residents with toileting and changing their adult briefs, LPA heard S1 exclaim loudly, "JESUS CHRIST!" After S1 was finished with her assistance to the residents, LPA conducted the interview with S1 privately in a separate room. Upon being asked what her loud exclamation pertained to, S1 stated, "I'm not gonna lie; I got poop on my wrist".

Therefore, based on LPA's observations, the following deficiency was cited per Title 22, Division 6 of the California Code of Regulations. See LIC 809D. An exit interview was conducted and a copy of this report was provided along with LIC811- Confidential Names list and Appeal Rights.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-8031
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:
DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/03/2023 02:06 PM - 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,
, CA


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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/04/2023
Section Cited

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Personal Rights of Residents in All Facilities-(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This regulation was not met as evidenced by: The licensee did not ensure the personal rights of all
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The licensee with retrain all staff on the resident's right to be treated with dignity. Proof of training to be provided by 5PM 3/4/2023.
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residents were maintained. Based on LPA's observation and statement of S1, S1 did not grant R1 and R2 dignity during S1's assistance with R1 and R2's toileting needs. This poses an immediate 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: 03/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2023
LIC809 (FAS) - (06/04)
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