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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 360902129
Report Date: 11/27/2024
Date Signed: 11/27/2024 01:55:01 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 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
11/19/2024 and conducted by Evaluator Sarina Ramirez
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20241119094936
FACILITY NAME:BRASWELL'S CHATEAU VILLAFACILITY NUMBER:
360902129
ADMINISTRATOR:MELANIE NIEZFACILITY TYPE:
740
ADDRESS:620 E. HIGHLAND AVENUETELEPHONE:
(909) 793-0433
CITY:REDLANDSSTATE: CAZIP CODE:
92374
CAPACITY:156CENSUS: 113DATE:
11/27/2024
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Administrator Melanie NiezTIME COMPLETED:
02:05 PM
ALLEGATION(S):
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9
Resident not receiving medications as prescribed
Facility did not refill residents medication as required
INVESTIGATION FINDINGS:
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2
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5
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Licensing Program Analysts (LPAs) Sarina Ramirez and Becky Mann conducted an unannounced visit to the facility to conduct a complaint investigation on the above allegations. LPAs met with Administrator Melanie Niez, and discussed the purpose of the visit.

Allegation #1 Resident not receiving medications as prescribed. The allegation is alleging that on 11/18/2024, facility staff did not administer one of R1’s medications as prescribed. Based on review of facility medications log, interviews with facility staff and residents in the facility the allegation is unsubstantiated. Facility staff interviews state the medication was dispensed as prescribed. Review of resident records reveals no evidence to support the allegation. Interviews with 6 residents in the facility could not corroborate the allegation.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2024
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 2
Control Number 56-AS-20241119094936
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: BRASWELL'S CHATEAU VILLA
FACILITY NUMBER: 360902129
VISIT DATE: 11/27/2024
NARRATIVE
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Allegation #2 Facility did not refill residents medication as required. The allegation is alleged that R#2 has not received their pain medication for a month. Based on review of facility medication log, interviews with facility staff and residents in the facility the allegation is unsubstantiated. Facility staff interviews state the refills are processed by the physicians authorization serviced by Innovage, VA, or Yucaipa care. Review of resident records reveals no evidence to support the allegation. Interviews with 6 residents in the facility could not corroborate the allegation

An Unsubstantiated complaint means, that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted with Administrator Niez and a copy of this report was provided to Administrator Melanie Niez at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2