360900521-11-29-2023-56-AS-BALN-CY33P4-20231129172455

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 360900521
Report Date: 11/29/2023
Date Signed: 11/29/2023 05:25:08 PM

Document Has Been Signed on 11/29/2023 05:25 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

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: 74	DATE:	11/29/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:35 PM
MET WITH:	Keely Miller-Administrator		TIME COMPLETED:	06:00 PM

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Licensing Program Analyst (LPA) Bernadette Allen made an unannounced visit to the facility for the purpose of conducting an annual inspection. LPA met with Administrator, Keely Miller.

LPA conducted an overall inspection of the facility, which included, but was not limited to, the following:

The Indoor and outdoor passageways were kept free of obstruction. The facility has sufficient furniture and lighting and is maintained at a comfortable temperature.

There was enough nonperishable and perishable food for the number of residents in care. The facility has a variety of food available for residents, and a menu was available for review. The facility food is stored in a safe and healthful manner.

The resident’s bedrooms are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting. All bathrooms were operating in a safe and sanitary conditions. The hot water temperature measured between 105- and 120-degrees F. LPA also observed the facility is equipped with operating carbon monoxide/smoke detectors and fully charged fire extinguishers.

Posters such as personal rights and the disaster plan were posted in a common area.The resident’s files were reviewed, and all files had the required documents at the time of the visit.

LPA observed that two(2) staff members files were missing current CPR training's a Technical Advisory(TA) was cited and attached to the lic809.LPA, also observed that medications were not signed by staff member at the time it was given and the facility staff did not ensure medications were not transferred between containers which pose a potential health, safety and personal rights risk to residents in care and has been cited on the attached 809-D

An exit interview was conducted with Keely Miller- Administrator where this report was discussed and provided at the conclusion of the visit with appeal rights.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette Allen	TELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023

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 11/29/2023 05:25 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, 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: 11/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(h)(5)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observations the facility staff did not ensure medications were not transferred between containers which pose potential health, safety and personal rights risk to residents in care.
	POC Due Date: 12/08/2023
	Plan of Correction
1 2 3 4	The licensee has agreed to provide training to all staff members (Med Tec) and provided a statement of understanding of the cited regulation by the POC date of 12/8/23.

Type B

Section Cited

CCR

87465(d)(3)

Incidental Medical and Dental Care Services

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observations the facility staff did not ensure MARS were siged at the time medications were given to the residents in care which pose potential health, safety and personal rights risks to resident in care.
	POC Due Date: 12/08/2023
	Plan of Correction
1 2 3 4	The licensee has agreed to provide training to all staff members (Med Tec) and provided a statement of understanding of the cited regulation by the POC date of 12/8/23.

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 Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette Allen	TELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023

LIC809 (FAS) - (06/04)

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