<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 360902129
Report Date: 07/28/2021
Date Signed: 07/28/2021 03:58:50 PM



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
05/17/2021 and conducted by Evaluator Elecia Weathersby
COMPLAINT CONTROL NUMBER: 18-AS-20210517144008
FACILITY NAME:BRASWELL'S CHATEAU VILLAFACILITY NUMBER:
360902129
ADMINISTRATOR:JAMES BRASWELLFACILITY TYPE:
740
ADDRESS:620 E. HIGHLAND AVENUETELEPHONE:
(909) 793-0433
CITY:REDLANDSSTATE: CAZIP CODE:
92374
CAPACITY:156CENSUS: 86DATE:
07/28/2021
UNANNOUNCEDTIME BEGAN:
12:28 PM
MET WITH:Wellness Director, Tammy ChavezTIME COMPLETED:
03:58 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
#1 Resident belongings are taken.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Elecia Weathersby made an unannounced visit to the facility to commence a complaint investigation. LPA identified herself and discussed the purpose of the call and the elements of the above allegation with Wellness Director, Tammy Chavez.

LPA conducted interviews with staff and several residents.
Allegation #1 Resident belongings are taken.
LPA Weathersby interviewed (3) staff members, and (1) resident regarding the above allegation. Staff members (S2), (S3) and resident (R1) confirmed that staff witnessed R2 consuming R1’s personal food. Staff also confirmed that R2 was scheduled to change rooms for several weeks, however had not been moved due to logistical reasons. LPA Weathersby determined that this was a violation of R1’s personal rights, as staff failed to respond timely to resolve the matter. Based on interviews conducted and evidence obtained, the allegations is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. California Code of Regulations are being cited and deficiencies noted on the attached LIC 9099D.

An exit interview was conducted where this report and appeal rights were discussed. A copy of all reports and forms, LIC 9099D, and appeal rights were provided to Wellness Director Tammy Chavez during the exit interview.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Elecia WeathersbyTELEPHONE: (951) 255-9516
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021
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 18-AS-20210517144008
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 CHATEAU VILLA
FACILITY NUMBER: 360902129
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/28/2021
Section Cited
CCR
87218(a)
1
2
3
4
5
6
7
 87218(a)
The licensee shall ensure an adequate theft and loss program... This requirement is
not met as evidenced by:
1
2
3
4
5
6
7
Licensee relocated residents. No action required
8
9
10
11
12
13
14
Based on interviews, LPA observatrion and facility document reviews, the licensee failed to resolve the violation of resident personal rights in a timely manner, which poses a potential health and safety risks 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: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Elecia WeathersbyTELEPHONE: (951) 255-9516
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2