360902129-11-16-2023-56-AS-MMAE-CXN3C5-20231116170724

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 360902129
Report Date: 11/16/2023
Date Signed: 11/16/2023 05:07:36 PM

Document Has Been Signed on 11/16/2023 05:07 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	BRASWELL'S CHATEAU VILLA		FACILITY NUMBER:	360902129
ADMINISTRATOR:	MELANIE NIEZ		FACILITY TYPE:	740
ADDRESS:	620 E. HIGHLAND AVENUE		TELEPHONE:	(909) 793-0433
CITY:	REDLANDS	STATE: CA	ZIP CODE:	92374
CAPACITY:	156; 156	CENSUS: 106	DATE:	11/16/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Melanie Niez, Administrator		TIME COMPLETED:	05:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Melanie Niez, Administrator, and discussed the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE). License capacity of (156) with a current census of (106). Hospice waiver for (20). LPA conducted an overall inspection of the facility, which included, but was not limited to, the following: PHYSICAL PLANT/INDOOR: Indoor passageways are free of obstruction. The facility has sufficient indoor space for resident activities. The facility has sufficient lighting and is maintained at a comfortable temperature. LPA inspected (6) resident bedrooms. Bedrooms were equipped with sufficient furniture, lighting, and bed linen in good repair. LPA inspected (6) bathrooms and (1) central bathroom. Bathrooms were equipment with grab bars and maintained in operating condition. Bathroom hot water temperatures measured between 105 and 107 degrees F. The facility is equipped with operating carbon monoxide alarms, telephone service, and laundry equipment. The facility has sufficient blankets, towels, and hygiene products for residents in care. Resident activities, Licensing complaint poster, Ombudsman poster, emergency phone numbers, evacuation plan, and "No Smoking-Oxygen in Use" signs were posted in the appropriate areas. Sharps, disinfectants, cleaning solutions, and toxins were kept locked and inaccessible to residents. PHYSICAL PLANT/OUTDOOR: Outdoor passageways are free of obstruction. Facility has no outdoor bodies of water.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BRASWELL'S CHATEAU VILLA	FACILITY NUMBER: 360902129
	VISIT DATE: 11/16/2023

NARRATIVE

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Courtyard area is protected from traffic and sufficient for resident activities. CARE & SUPERVISION: Facility has 24-hour/7 days a week care staff.
FOOD SERVICE: Facility has sufficient non-perishable and perishable food supply for residents in care. The refrigerator and freezer are operating in a healthful manner. Pesticides and other cleaning solutions were kept locked and stored away from food areas.
MEDICAL RELATED SERVICES: Facility has complete first aid kits. Medications were observed locked and inaccessible to residents. Medications for (6) residents were inspected. Medications for resident #1 (R1) were not administered as prescribed as medications for days past were observed still in the bubble packet with no documentation to why medication was not given. Medications for resident #2 (R2) were not administered as prescribed as medications for days past were observed still in the bubble packet with no documentation to why medication was not given. Medications for resident #3 (R3) were observed to be in a zip lock bag without a prescription label. Medications for resident #4 (R4) were not administered as prescribed as medications for days past were observed still in the bubble packet with no documentation as to why medication was not given.
RECORDS REVIEW: Administrator certification expires on 8/18/2024. The last emergency drill was conducted on 11/07/23. Records for (6) staff were reviewed. The facility did not maintain verification of food service training for staff #1(S1) on file. The facility did not maintain verification of staff #2 (S2) CPR/first aid training on file. Records for (6) residents were reviewed. The facility did not maintain record of R3's preadmission appraisal on file.
Deficiencies are being cited during today's visit and a plan of correction was reviewed with the Administrator. Copies of licensing reports discussed were provided to the Administrator with appeal rights at the conclusion on the visit.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/16/2023 05:07 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BRASWELL'S CHATEAU VILLA	FACILITY NUMBER: 360902129
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(4)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observations, the licensee did not comply with the section cited above by medications for resident #3 (R3) were observed to be in a zip lock bag without a prescription label, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/20/2023
	Plan of Correction
1 2 3 4	Licensee/administrator shall submit to the Licensing Agency a statement of understanding on regulation cited by POC due date.

Section Cited

Incidental Medical and Dental Care Services


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/16/2023 05:07 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BRASWELL'S CHATEAU VILLA	FACILITY NUMBER: 360902129
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Incidental Medical and Dental Care Services


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Type A

Section Cited

CCR

87465(c)(2)

(c) facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observations, the licensee did not comply with the section cited above by Medications for resident #1 (R1) were not administered as prescribed as medications for days past were observed still in the bubble packet with no documentation to why medication was not given. Medications for resident #2 (R2) were not administered as prescribed as medications for days past were observed still in the bubble packet with no documentation to why medication was not given. Medications for resident #4 (R4) were not administered as prescribed as medications for days past were observed still in the bubble packet with no documentation as to why medication was not given, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/20/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator shall conduct an inservice training with Medtechs on medication management and submit proof of training to the Licensing Agency by POC due date.

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: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/16/2023 05:07 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BRASWELL'S CHATEAU VILLA	FACILITY NUMBER: 360902129
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(c)

Personnel Records

(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA record review, the licensee did not comply with the section cited above by not maintaining verification of food service training for staff #1(S1) on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/30/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator shall submit to the Licensing Agency proof of training by POC due date.

Type B

Section Cited

CCR

87411(c)(1)

Personnel Requirements - General

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA records review, the licensee did not comply with the section cited above by not maintaining verification of staff #2 (S2) CPR/first aid training on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/30/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator shall submit to the Licensing Agency proof of training by POC due date.

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: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/16/2023 05:07 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BRASWELL'S CHATEAU VILLA	FACILITY NUMBER: 360902129
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87457(c)

Pre-Admission Appraisal

(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA record review, the licensee did not comply with the section cited above by not maintaining record of R3's pre-admission appraisal on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/30/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator shall submit to the Licensing Agency documentation of resident appraisal by POC due date.

Section Cited

Pre-Admission Appraisal


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023

LIC809 (FAS) - (06/04)

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