360900521-5-4-2021-18-AS-JESL-C2VV6S-20210510161000

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 360900521
Report Date: 05/04/2021
Date Signed: 05/04/2021 10:21:15 AM

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
05/04/2020 and conducted by Evaluator Javina George

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200504120459

FACILITY NAME:	BRASWELL'S MEDITERRANEAN GARDENS		FACILITY NUMBER:	360900521
ADMINISTRATOR:	VIRGINIA BAUER		FACILITY TYPE:	740
ADDRESS:	12295 4TH STREET		TELEPHONE:	(909) 797-1131
CITY:	YUCAIPA	STATE: CA	ZIP CODE:	92399
CAPACITY:	130	CENSUS: 72	DATE:	05/04/2021
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Administrator Keely Miller		TIME COMPLETED:	09:30 AM

ALLEGATION(S):

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Facility is operating beyond the terms and conditions of the license.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Javina George contacted Administrator Keely Miller via telephone for the purpose of delivering findings for the allegation listed above. LPA Javina George explained the purpose of the call.

The allegation was investigated by the department. The investigation consisted of a review of the facility history of requests for services and what they are licensed for.

LPA George received and reviewed documents such as a facility roster, which indicates that the facility was operating beyond the terms and conditions of the license. The facility is only approved to have 5 residents on hospice. At the time of the complaint the facility had 7 resident's that were on hospice.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2020

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 4

Control Number 18-AS-20200504120459

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: 05/04/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/18/2021 Section Cited CCR 87623(a)(1)	1 2 3 4 5 6 7	87632 Hospice Care Waiver (a) In order accept or retain terminally ill residents and permit them to receive care from a hospice agency, the licensee shall have obtained a facility hospice care waiver from the Department. To obtain this waiver the licensee shall submit a written request for a waiver to the Department on behalf of any residents who may request retention, and any future residents who may request acceptance, along with the provision of hospice services in the facility. The request shall include, but not be limited to the following:(1)Specification of the maximum number of terminally ill residents which the facility wants to have at any one time. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The licensee will request a hospice waiver increase and submit it to the department by 5pm, on the due date indicated.
	8 9 10 11 12 13 14	Based on observation, interview and record review the licensee did not operate within capacity limitations. The facility having 2 additional residents on hospice. When they are only approved for 5. This poses a potential Health, Safety, or Personal Rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 18-AS-20200504120459

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: 05/04/2021

NARRATIVE

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The allegation of Facility is operating beyond the terms and conditions of the license is SUBSTANTIATED. The allegations of a finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Based on the investigation findings, deficiencies were observed and cited according to California Code of Regulations, Title 22, Division 6 and listed on the attached 9099D.

An exit interview was conducted and a copy of this report, 9099C, LIC 9099D and appeal rights were provided to the Administrator Keely Miller via email. LPA George also requested for Keely to sign the report and send it back to LPA.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 4

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
05/04/2020 and conducted by Evaluator Javina George

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200504120459

FACILITY NAME:	BRASWELL'S MEDITERRANEAN GARDENS		FACILITY NUMBER:	360900521
ADMINISTRATOR:	VIRGINIA BAUER		FACILITY TYPE:	740
ADDRESS:	12295 4TH STREET		TELEPHONE:	(909) 797-1131
CITY:	YUCAIPA	STATE: CA	ZIP CODE:	92399
CAPACITY:	130	CENSUS: 72	DATE:	05/04/2021
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Administrator Keely Miller		TIME COMPLETED:	09:30 AM

ALLEGATION(S):

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Staff unlawfully evicted resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Javina George contacted Administrator Keely Miller via telephone for the purpose of delivering findings for the allegation listed above. LPA George explained the purpose of the call.

The investigation consisted of interviews and a review of documentation such as the eviction notice for R1. However, the facility was unable to provide the requested documentation. Additionally, the previous administrator did confirm that an eviction notice was issued for R1, and that there should be a copy in R1s file, and another copy in the facility copy book. R1 would constantly scream and yell in the dining room. R1 was physically combative with the other residents, and would use profanity. Due to the disruptive nature R1 was issued the eviction notice. Keely stated that the family moved R1 out the weekend before the notice was up.
The allegation of Staff unlawfully evicted resident is UNSUBSTANTIATED.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 4