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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 360900521
Report Date: 02/18/2022
Date Signed: 02/18/2022 05:00:56 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
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/22/2021 and conducted by Evaluator Yolanda Delgado
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210322104401
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: 60DATE:
02/18/2022
UNANNOUNCEDTIME BEGAN:
04:24 PM
MET WITH:Krista Overmyer, Med TechTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Facility staff did not use proper lifting techniques resulting in resident breaking arm
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Yolanda Delgado arrived to the facility, unannounced, to conclude an investigation pertaining to the listed allegation. LPA identified herself and met with Krista Overymyer, Med Tech. LPA discussed the purpose of the visit and the elements of the allegation.

It was reported that facility staff did not use proper lifting techniques, resulting in Resident’s arm being injured. It was stated that Resident #1 was pulled out of the bed utilizing a sheet and Resident’s arm, which caused the injury. LPA Delgado reviewed Resident #1’s care plan and it stated that staff were required to use a lift when assisting Resident #1. Information obtained from interviews, stated that staff members did not use the lift, as required for maximum assistance with all activities of daily living for Resident #1. It was advised that Staff #1 and Staff #2 were not trained in utilizing the Hoyer Lift, which was available.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda DelgadoTELEPHONE: (951) 203-0337
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2022
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 3
Control Number 18-AS-20210322104401
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
RIVERSIDE, CA 92507

FACILITY NAME: BRASWELL'S MEDITERRANEAN GARDENS
FACILITY NUMBER: 360900521
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/25/2022
Section Cited
HSC
80072(a)(2)
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Personal Rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs... This requirement was not met by:
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Licensee agreed to have all staff providing care to residents trained on Hoyer Lift and understanding and abiding by resident’s care plans. Acknowledgement and proof of training will be provided to LPA Delgado by the requested date.
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Based on records review and interviews, the Licensee did not comply with the above regulation with at least two staff trained to use Hoyer Lift to assist Resident #1 with ADL's and the resident's care plan . This is an immediate Health and Safety 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: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda DelgadoTELEPHONE: (951) 203-0337
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20210322104401
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
RIVERSIDE, CA 92507
FACILITY NAME: BRASWELL'S MEDITERRANEAN GARDENS
FACILITY NUMBER: 360900521
VISIT DATE: 02/18/2022
NARRATIVE
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Based on LPAs observations, interviews, and records review, the preponderance of evidence standard has been met; therefore, the above allegation is 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. A copy of the report, along with the LIC 9099-D and appeal rights were provided.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda DelgadoTELEPHONE: (951) 203-0337
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3