Braswell's Mediterranean Gardens

Allegation investigated: Staff are not following infection control protocol

Licensing Program Analyst (LPA) Paola Guerrero arrived at the facility to deliver the investigative findings. Upon arrival, LPA met with Facility Administrator Maria Cervantes and explained the purpose of the visit, which was to discuss the investigative findings related to the allegation described above. Allegation: Staff are not following infection control protocols. Regarding the allegation, LPA conducted an inspection of the facility’s personal protective equipment (PPE) and infection control supplies. During the inspection, LPA observed the required quantities of face shields, face masks, gowns, and gloves stored in the medication room. LPA interviewed Staff #1 and Staff #2 regarding the allegation and requested that staff identify the location where disinfectants and materials used for containment and cleanup of bodily fluids are maintained. Staff #1 and Staff #2 stated that the facility does not currently have spill kits available. Staff reported that, when cleaning bodily fluids, such as vomit, the facility provides staff with incontinence absorbent mats and bleach for cleanup. Substantiated Staff #1 and Staff #2 further stated that gloves and masks are provided to staff. LPA requested documentation demonstrating that staff had received training regarding the proper procedures for cleaning bodily fluid spills and the appropriate disposal of biohazardous materials. Staff #1 and Staff #2 were unable to provide documentation of training related to these procedures. Based on the information obtained through observation, staff interviews, and the review of available training documentation, LPA determined that the facility had not demonstrated that staff were adequately trained in the proper procedures for cleaning bodily fluid spills and disposing of biohazardous materials. Although PPE was observed to be available at the facility, the lack of spill kits and the inability to provide documentation of staff training regarding the proper handling and disposal of bodily fluids support the allegation. Based on the evidence obtained during the investigation, LPA determined that the allegation that staff are not following infection control protocols is substantiated. A finding that the complaint is Substantiated means that the findings are valid because the preponderance of the evidence standard has been met. Title 22 Regulations, from division 6, chapter, article 6, is, cited on the attached LIC 9099 D. An exit interview was conducted where this report, appeal rights, and LIC9099-D was discussed, and a copy of the report was provided to Facility Administrator Maria Cervantes at the conclusion of the visit.the state’s words, verbatim · CDSS document, Sep 21, 2026 · control 56-AS-20260612115850

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87470(a)(2)(C)(D) · Plan of correction due date: Sep 28, 2026

Infection Control Requirements 87470 (a) A licensee shall ensure that infection control practices are maintained as follows…. (2) Environmental cleaning and disinfection activities shall be performed following the manufacturers' instructions for proper use of the cleaning and disinfecting products. These activities shall be completed, at a minimum, as follows…. (C) Spills of blood and other potentially infectious materials and surfaces shall be promptly cleaned and disinfected…(D) Facility items that cannot be disinfected shall be discarded immediately in an appropriate waste receptacle with a tight-fitting cover or otherwise made inaccessible to human contact or transmission. This requirement is not met as evidence by: Based on observation, interviews, and record review, the licensee did not adhere to infection control requirements by not having the required disinfectants and training available, which poses a potential health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 21, 2026

Plan of correction: The Licensee has agreed to read over regulation: Infection Control Requirements 87470 (a)(2)(C)(D) and provide training to all staff to ensure all staff are trained in the proper procedures on how to clean bodily fluids and spills and proper disposal of biohazard material. The Licensee will also purchase proper disinfectants and provide LPA with invoices. In addition, the Licensee will provide LPA with proof of training by emailing LPA a copy of the training signed and dated by all staff by POC date 9/28/2026.

Type of visit: Case Management - Other

On August 6, 2026, Licensing Program Analyst (LPA) E. Conchas, made an unannounced case management visit to the facility to deliver an amended report on complaint number 56-AS-20260624123648. LPA met with Assistant Administrator, Maria Cervantes and explained the reason for the visit. During today's visit, LPA conducted a tour of the facility for a Health & Safety Check. Based on today's observations made, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted where this report was discussed, and a copy was provided to Administrator Cervantes.the state’s words, verbatim · CDSS document, Aug 6, 2026

Type of visit: Case Management - Other

Licensing Program Analysts (LPA) Edith Conchas conducted an unannounced visit to the facility for the purpose of a Case Management Visit on complaint numbers 56-AS-20260420105511 , 56-AS-20260612115850, 56-AS-20260624123648. LPA identified thyself to Administrator assistant Maria Cervantes and discussed the purpose of the visit. LPA interviewed staff and residents in care in addition to doing a walk through around the facility. No imminent health and/or safety hazards inside or outside the facility were observed. LPA observed staff present at the facility providing care, activities and maintenance updates. Based on today's observations made, no deficiencies were cited per Title 22, of the California Code of Regulations. An exit interview was conducted where this report was discussed, and a copy was provided to Administrator assistant Cervantes.the state’s words, verbatim · CDSS document, Jul 30, 2026

Allegation investigated: Staff not properly trained. Staff left residents in soiled diapers resulting in rashes. Insufficient staffing to provide assistance to residents. Unqualified staff administering medication. Staff do not maintain an adequate amount of supplies. Staff are not providing basic laundry service. Staff do not prevent outbreak of scabies. Staff do not prevent outbreak of covid.

Licensing Program Analyst (LPA) Paola Guerrero arrived at the facility to deliver investigative findings. LPA met with Facility Administrator Maria Cervantes and explained the purpose of the visit regarding the allegation stated above. First allegation: Staff not properly trained. Regarding the allegation stated above, LPA conducted interviews with Staff #1-3 regarding the alleged allegation and Staff #1-3 denied the allegation and informed LPA that all care staff receive the proper training upon hire and continuous training throughout the year. Staff #1 provided LPA with medtech certificates of completion along with caregiving training. LPA conducted a record review of all certificates and training courses and discovered all certificates to be current and hours of training to be documented. Second allegation: Staff left residents in soiled diapers resulting in rashes. Regarding the allegation stated above, LPA conducted interviews with Staff #1-3 regarding the alleged allegation and Staff #1-3 denied the allegation and informed LPA that all residents receive proper incontinence care. Unsubstantiated In addition, Staff #1-3 denied the allegation of staff leaving residents in soiled diapers for long period of time resulting in rashes. Staff #3 informed LPA that frequent diaper checks (every 2-3 hours), are implemented as residents can soil a diaper minutes after changing. LPA conducted interviews with Residents #1-5 regarding the alleged allegation and Resident #1-5 denied the allegation and informed LPA that caregivers are tentative and provide adequate care. Resident #1-5 informed LPA that they have not been left in soiled diapers for long period of time resulting in rashes. Resident #1-5 informed LPA that staff provide them with incontinence brief change when needed. Third allegation: Insufficient staffing to provide assistance to residents. Regarding the allegation stated above, LPA conducted an interview with Staff #1 regarding the alleged allegation Staff #1 denied the allegation and provided LPA with most recent employee roster and informed LPA that the facility is currently staffed. Staff #1 informed LPA that facility does receive no call no show however, facility has enough care support to cover. LPA conducted interviews with Residents #1-5 regarding the alleged allegation and all residents informed LPA that in the past the facility might have been short staffed however, caregiver still provided residents with their care needs. Resident #1-5 informed LPA that they do not have any concerns right now regarding staff support as their care needs are being met. Fourth allegation: Unqualified staff administering medication. Regarding the allegation stated above, LPA conducted interviews with Staff #1-3 regarding the alleged allegation and Staff #1-3 denied the allegation and informed LPA that all MedTechs complete 16 hours of hands-on training on Medication Verification along with 24-hour training on Assisted Living Medication training. Staff #1 provided LPA with certificates and training longs. LPA conducted a record review of all certificates and training courses and discovered all certificates to be current and hours of training to be documented. Fifth allegation: Staff do not maintain an adequate amount of supplies. Regarding the allegation stated above, LPA conducted an interview with Staff #1 regarding the alleged allegation and Staff #1 informed LPA that supply orders are placed twice a month and as needed. Staff #1 provided LPA with supply invoices. LPA conducted a review of record and observed that the last supply order was placed on June 18,2026 for Continental Pacific. LPA conducted interviews with Staff #2, Staff #3, regarding the alleged allegation and all staff denied the allegation and informed LPA that the facility maintains a good number of supplies stored and available for staff and residents’ usage. LPA inspected two supply closets located in the facility and observed facility to have Personal Protective Equipment (PPE) supply, items such as gloves, gowns, disinfectants, N95 masks, and hand sanitizer. in addition, LPA also observed toileting supplies, and incontinence supplies to be stored. Sixth allegation: Staff are not providing basic laundry service. Regarding the allegation stated above, LPA conducted an interview with Staff #2 regarding the alleged allegation and Staff #2 informed LPA that the facility provides residents with laundry services once a week Monday-Friday per area. Staff #2 further indicated that laundry services are also provided as needed for residents who have urinary and bowel incontinence. LPA conducted an interview with Staff #1 who informed LPA that laundry services are provided and part of the resident’s admission. Staff #1 provided LPA with laundry log. LPA conduct a review of records and observed laundry services to be provided Monday-Friday. LPA also observed laundry services for residents with incontinence care. Seventh allegation: Staff do not prevent outbreak of scabies. Regarding the allegation stated above, LPA conducted an interview with Staff #1 and Staff #2 regarding the alleged allegation and Staff #1-2 denied the allegation and informed LPA that on two separate incidents 2/14/2026 and 2/21/2026, two residents were diagnosed with scabies. Staff #1 and Staff #2 informed LPA that all care staff were informed Personal Protective Equipment (PPE), was provided to staff and facility followed their infectious control plan against scabies. Staff #1 and Staff #2 informed LPA that both residents were treated, and no reports of scabies have occurred since both cases. LPA conducted an interview with Staff #3 regarding the alleged allegation and Staff #3 informed LPA that there has not been any recent report of scabies at the facility. Staff #3 informed LPA that there have been two separate incidents regarding residents being diagnosed with scabies. Staff #3 further indicated that during both incidents staff were made aware; residents were treated and the facility provided staff with the necessary PPE supplies as preventative measures. Eight allegation: Staff do not prevent outbreak of covid. Regarding the allegation stated above, LPA conducted interviews with Staff #1-3 regarding the alleged allegation and Staff #1-3 denied the allegation and informed LPA that for the past year the facility has not had any Positive COVID cases reported. LPA conducted interviews with Residents #1-5 regarding the alleged allegation and all residents denied the allegation and informed LPA that they cannot recollect when the facility had a COVID outbreak. Resident #1-5 further stated that they have not witnessed any resident test positive for COVID in the past few months. Based on corroborating evidence LPA has determined that the above allegation is Unsubstantiated, meaning that 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. An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to Facility Administrator Maria Cervantes.the state’s words, verbatim · CDSS document, Jul 11, 2026 · control 56-AS-20260302095529

Allegation investigated: Staff do not ensure residents have transprotation to appointments. Staff are not meeting residents dietary needs. Staff ignore residents.

Licensing Program Analyst (LPA) Paola Guerrero arrived at the facility to deliver investigative findings. LPA met with Facility Administrator Maria Cervantes and explained the purpose of the visit regarding the allegation stated above. First allegation: Staff do not ensure residents have transportation to appointments. Regarding the allegation stated above, LPA conducted an interview with Staff #1 regarding the alleged allegation. Staff #1 informed LPA that majority of residents at the facility utilize InnovAge for transportation. Staff #1 further stated that if a resident is referred to see a specialist the facility will make transportation arrangements with the resident. LPA conducted interviews with Residents #1-5 regarding the alleged allegation and Residents #1-3 informed LPA that their primary physician comes to the facility and provides routine check-ups. Resident #4 and Resident #5 informed LPA that InnovAge provides them with transportation for all their appointments. Residents #1-5 denied the allegation and informed LPA that the facility assists residents with transportation to medical appointments when needed. Unsubstantiated Second allegation: Staff are not meeting residents’ dietary needs. Regarding the allegation stated above, LPA conducted an interview with Staff #1 regarding the alleged allegation Staff #1 informed LPA that the facility does have residents that are on special food diets. Staff #1 provided LPA with a list of all residents that are on a special food diet. Staff #1 denied that allegation and indicated that the facility does their best to meet resident’s dietary needs. LPA conducted interviews with Resident #1-4 regarding the alleged allegation and Residents #1-4 denied the allegation and informed LPA that they have no issues to report regarding their meals and stated that the facility meets their dietary needs daily. Third allegation: Staff ignore residents. Regarding the allegation stated above, LPA conducted an interview with Staff #1 regarding the alleged allegation and Staff #1 denied the allegation. Staff #1 informed LPA that they have not witnessed residents being ignored by staff. LPA conducted interviews with Resident #1-5 regarding the alleged allegation and Resident #1-5 denied the allegation and informed LPA that all staff are nice and respectful. Resident #1-5 informed LPA that staff respond to residents when assistance is needed. Resident #1-5 further indicated that they have no issues to report concerning their care. Based on corroborating evidence LPA has determined that the above allegation is Unsubstantiated, meaning that 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. An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to Facility Administrator Maria Cervantes.the state’s words, verbatim · CDSS document, Jul 9, 2026 · control 56-AS-20260323082445

Allegation investigated: Facility does not have adequate meal service. Facility smells of urine. Staff does not ensure that resident's room are properly cleaned.

Licensing Program Analyst (LPA) Paola Guerrero arrived at the facility to deliver investigative findings. LPA met with Facility Administrator Maria Cervantes and explained the purpose of the visit regarding the allegation stated above. First allegation: Facility does not have adequate meal service. Regarding the allegation stated above, LPA conducted an interview with Staff #1 regarding the alleged allegation. During the interview Staff #1 provided LPA with facilities monthly food menu. During the review of the monthly food menu LPA observed that the facility provides adequate meal service along with weekly alternative meal choice to residents. Staff #1 informed LPA that the facility receives food delivery twice a week (Tuesday & Friday), Staff #1 provided LPA with delivery invoices. LPA conducted a food inspection and observed that the facility has enough food supply to meet the number of residents in care. LPA conducted interviews with Resident #1-5 regarding the alleged allegation and all residents informed LPA that the food that is being served at the facility is decent, and that they have no concern regarding the food. In addition, residents reported that facility provides meal alternatives. Unsubstantiated Second allegation: Facility smells of urine. Regarding the allegation stated above, LPA conducted an interview with Staff #1 regarding the alleged allegation. Staff #1 informed LPA that housekeeping performs deep cleaning in resident’s rooms once a week and basic cleaning is done daily and as needed. LPA conducted a walkthrough of the facility and observed that several rooms have been renovated. During the walkthrough LPA observed that overall, the facility is decent, in good repair and free of odors. Third allegation: Staff does not ensure that resident's room are properly cleaned. Regarding the allegation stated above, LPA conducted an interview with Staff #1 regarding the alleged allegation. Staff #1 informed LPA that for the past three (3) months the facility has renovated a total of seventeen (17) bedrooms. Staff #1 provided LPA with renovation invoices. Staff #1 further informed that every month the facility renovates two bedrooms. LPA conducted a walkthrough of the facility and observed residents’ bedrooms to be clean, free of bugs, and free of odors. Based on corroborating evidence LPA has determined that the above allegation is Unsubstantiated, meaning that 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. An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to Facility Administrator Maria Cervantes.the state’s words, verbatim · CDSS document, Jul 8, 2026 · control 56-AS-20260302151211

Allegation investigated: Staff are opening residents' mail Staff are stealing residents' checks Staff did not assist resident with incontinent needs

Licensing Program Analyst (LPA) E. Conchas arrived to the facility to conduct a complaint investigation regarding the allegations above. LPA met with Maria Cervantes and explained the elements of the investigation. LPA conducted a tour of the facility, interviewed staff, residents and obtained pertinent documents. LPA met with Facility Assistant Administrator Maria Cervantes and explained the purpose of the visit. Allegation: Staff are opening residents’ mail. LPA interviewed 3 staff and all three staff denied the allegation. Interviews with S1 and S2 revealed mail is handed to the residents. Interview with S3 revealed mail has been observed left on resident’s beds. Interviews with five (5) residents, R1, R3, R4, R11, and R12, who receive mail, denied the allegation and confirmed they have not experienced problems with receiving their mail. This allegation is Unsubstantiated. Continue to LIC9099-C Unsubstantiated Allegation: Staff are stealing residents’ checks. LPA conducted Interviews with three staff, and they denied the allegation. Interviews with S1 and S2 reveal any checks received are forwarded to accounting and are not dealt with at the facility. The interview with S2 revealed the checks that have been observed by S2 are addressed to the facility and not the client. The interview with S3 reveals they have never observed or heard of any staff stealing residents’ checks. Interviews with four (4) residents, R1, R3, R4, R11, and R12, who receive mail, reveal they have not had any checks stolen or missing. This allegation is Unsubstantiated. Allegation: Staff did not assist residents with incontinent needs. LPA conducted interview with three staff, and they denied the allegation. Interviews with S1 and S2 reveal the residents get routine two-hour checks. The interview with S3 reveals they have observed, over the years, an increase in care needs and that it is being provided. S1 provided LPA with a list identifying residents and their room numbers who require two-hour checks. Interviews with four (4) residents, R3, R5, R7, and R10, who require incontinent care, deny the allegation and confirm that staff assist them with their incontinent needs. This allegation is Unsubstantiated. Based on the information obtained, LPA has determined that the above allegations are deemed unsubstantiated at this time. Although the allegations may have occurred or may be valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur; therefore, the allegations remain unsubstantiated. An exit interview was conducted where this report was discussed, and a copy was provided to Facility Assistant Administrator Maria Cervantes.the state’s words, verbatim · CDSS document, Jul 2, 2026 · control 56-AS-20260624123648

Allegation investigated: Staff do not follow physicians orders. Staff left resident in soiled linens. Staff are not trained properly for transfers resulting in staff dropping resident. Due to lack of staff, residents are not fed timely. Due to lack of staff, residents needs are not being met.

Licensing Program Analyst (LPA) Andrew Martinez made an unannounced visit to continue the complaint investigation and deliver findings for the above allegations. LPA met with Maria Cervantes, Administrator, who was informed of the purpose of the visit and allegations. Today's continuation of the investigation consisted of interviews of current staff and residents, LPA's observations, and records review. Resident #1 (R1) no longer resides at the facility as of September 18, 2024 and could not be interviewed. The allegations indicate: Staff do not follow physicians orders. – Based on staff interviews and observation of medical records, staff acted in accordance with physician orders as reflected in the updated medical records provided to the facility. Based on the evidence, the allegation is UNSUBSTANTIATED. ***Continued on LIC 9099-C*** Unsubstantiated Staff left resident in soiled linen. - Based on staff and resident interviews conducted, the information obtained did not yield sufficient evidence to substantiate the allegation under the preponderance of evidence standard. Based on lack of evidence, the allegation is UNSUBSTANTIATED. Staff are not trained properly for transfers resulting in staff dropping resident. - Based on staff interviews and review of facility's unusual or special incident reports (UIR/SIR) submitted to Licensing, no incidents involving a resident falling were identified as them being dropped resulting from inadequate staff training. Based on resident interviews, no resident reported they have been dropped or sustained any falls related to inadequate staff training. Based on the evidence, the allegation is UNSUBSTANTIATED. Due to lack of staff, residents are not fed timely. - Based on today's interviews with staff and residents, interviews confirmed that meals are provided within a reasonable timeframe during routine mealtimes, including breakfast at approximately 8:00 a.m., lunch at 12:00 p.m., and dinner at 5:00 p.m. Based on the evidence, the allegations mentioned above are UNSUBSTANTIATED. Due to lack of staff, residents needs are not being met. - Based on a review of the facility’s LIC 500 reports and staffing schedules for August and September 2024, as well as today, records indicate the facility employed and currently employs an adequate amount of staff to meet the needs of residents. Based on interviews conducted, staff and residents reported that resident's care needs are ultimately met and fulfilled, despite occasional inconsistencies in staff's response times. Based on the evidence, the allegation is UNSUBSTANTIATED. During the complaint investigation, LPA could not find evidence to corroborate the allegations mentioned above. A finding that the complaint is UNSUBSTANTIATED means 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 at this time. An exit interview was conducted where this report (LIC 9099 and LIC 9099-C) was discussed, and a copy was provided to Administrator, Maria Cervantes.the state’s words, verbatim · CDSS document, May 21, 2026 · control 56-AS-20240916124147

Allegation investigated: Staff do not answer call buttons in a timely manner Staff inappropriately speaks to residents

On April 27th, 2026 Licensing Program Analyst (LPA) Edith Conchas made an unannounced visit to the facility to conduct a complaint investigation regarding the above allegations. LPA explained the purpose of the visit to Assistant Administrator, Maria Cervantes. The investigation consisted of interviews with staff and residents, review of pertinent documents and a facility tour. Staff do not answer call buttons in a timely manner Based on staff interviews, 3 out of 6 staff revealed it takes 5-10 minutes to answer the call light, 2 out 6 staff stated they do answer in a timely manner. Resident interviews reveal 6 out of 8 residents stated yes staff answer call buttons in a timely manner. Based on interview, this allegation is UNSUBSTANTIATED. Staff inappropriately speaks to residents Based on staff interviews 6 out of 7 staff stated staff do not speak inapproprialy with residents. Interviews with residents reveal 7 out 8 residents stated No staff do not speak inappropriately to residents.Based on interviews, this allegation is UNSUBSTANTIATED. Continue LIC9099-A Unsubstantiated R5 interview reveals every once in a while when staff have time they will check in. Interview with R6 stated staff will check in with R6 if they call. Based on interviews, this allegation is susbtantiated. Based on interviews, and record review, the allegation 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. During today’s visit, two deficiencies were issued. An exit interview was conducted, and this report and appeal rights were discussed and provided to Assistant Administrator, Maria Cervantesthe state’s words, verbatim · CDSS document, Apr 27, 2026 · control 56-AS-20260420105511

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87618(b)(3)(C) · Plan of correction due date: Apr 28, 2026

87618Oxygen Administration - Gas and Liquid (b)(3) (C) Ensuring that the use of oxygen equipment meets the following requirements:(C)Smoking shall be prohibited where oxygen is in use. This requirement is not met as evidenced by: Based on interviews, the licensee did not ensure residents are not smoking inside the facility, which poses an immedtiate Health, Safety or Personal Rights risk to resident in care.the state’s words, verbatim · CDSS document, Apr 27, 2026

Plan of correction: Licensee will do an inservice training with staff and a reading counciling with residents on the No smoking policy inside the facility and submit a copy of the inservice training to LPA by POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Apr 28, 2026

87411 Personnel Requirements - General(a)Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... such additional staff for the provision of adequate services.This requirement is not met as evidenced by: Based on interviews with 2 resident interviews reveal there is no staff checks at night during night shift when are short staffed which poses an immedtiate Health, Safety or Personal Rights risk to resident in care.the state’s words, verbatim · CDSS document, Apr 27, 2026

Plan of correction: Licensee will conduct an inservice to all staff regarding regular resident check ups during all shifts and will submit a copy of completion by POC date.

Type of visit: Case Management - Other

On March 24, 2026, Licensing Program Analyst's (LPAs) Andrew Martinez and Edith Conchas, made an unannounced case management visit to the facility regarding complaint number 56-AS-20240916124147. LPAs met with Administrator Maria Cervantes and explained the reason for the visit. During today's visit, LPAs conducted staff interviews and obtained additional documents pertinent to the complaint investigation. Administrator Cervantes was advised that at this time the complaint requires further investigation. LPA(s) will need to complete follow-up telephone calls and/or visits before reaching investigative findings. Based on today's observations made, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted where this report was discussed, and a copy was provided to Administrator Cervantes.the state’s words, verbatim · CDSS document, Mar 24, 2026

Type of visit: Case Management - Deficiencies

On 3/10/2026, Licensing Program Analyst's (LPA's) E. Conchas and Andrew Martinez made an unannounced visit to the facility to initiate a complaint investigation for complaint numbers 56-AS-20260302095529 and 56-AS-20260302151211. LPA's met with Maria Cervantes and explained the reason for the visit. LPA's observed two (2) staff files with no finger print cleared. A citation was issued. One deficiency was cited during this visit. An exit interview was conducted where this report and appeal rights were discussed and copies were provided to Maria Cervantes, Assistant administrator.the state’s words, verbatim · CDSS document, Mar 10, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Mar 11, 2026

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b): shall prior to working... in a licensed facility: (2) obtain a California clearance... as required by the Department. The requirement is not met as evidence by Based on observation the license did not ensure staff properly obtained background check/ criminal record clearance prior to being hired at the facility which poses an immediate health and safety risk.the state’s words, verbatim · CDSS document, Mar 10, 2026

Plan of correction: Licensee will immediately have staff submit a criminal background clearane request to the state licensing and associate all staff to facility profile on Guardian. Once approved Licensee will submit proof of copy via email.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA’s) E. Conchas and LaVette Farlow made an unannounced visit to the facility to conduct a required comprehensive annual inspection. LPA met with Maria Cervantes, Administrator Assistant who assisted with the tour of the facility. Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature 75 degrees throughout the facility. LPA inspected resident’s bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. The hot water temperature measured at 124.7, 119.7, and 123.5 degrees F. throughout the facility. LPA observed the facility is equipped with operating smoke detectors, fully charged fire extinguisher, and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. LPA observed there was a designated storage space for resident/staff files. Medications are kept locked in the medication room inaccessible to residents in care. LPA audited and observed 4 resident MARs with discrepancies a Technical Assistance was issued. LPA observed Family Council, Long Term Ombudsman Rights Of Individual , Menu, and Activities Calendar in display. Overall, the facility is clean, in good repair, and operating in safe condition. Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department. Record Review: LPA reviewed resident files for admission agreements, updated physician reports, and needs and services plans. LPA observed Physician Report information was not filled out completely a Technical Assistance was issued. P&I was randomly checked and appeared to balance with ledger. Emergency disaster plan should be updated annually or as changes made and Plan Of operation should be updated when retaining bedridden residents and or changes to hospice A Technical Assistance was issued. LPA also reviewed staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. Based on the observations made during today’s visit, 4 Technical Assistance were issued. An exit interview was conducted, and this report was discussed and provided to Maria Cervantes, Administrative Assistant and Dori Loo, Director Of Operations and Clinical Services at the conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Dec 9, 2025

The state marks this report as 7 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff inappropriately told the paramedics resident had dementia Staff did not allow resident to view her records

On September 8th, 2025 Licensing Program Analyst’s (LPAs) Edith Conchas and Renese Howell-Small made an unannounced visit to the facility to conduct a complaint investigation regarding the above allegations. LPAs explained the purpose of the visit to the Director of Operations and Clinical Services, Dorie Loo. The investigation consisted of file review, interviews with staff and resident(s). #1 Staff inappropriately told the paramedics resident had dementia– Based on interview, 3 out of 3 staff stated Braswell’s Family Senior Care does not accept residents with Dementia unless a resident receives Hospice care. Staff 1 stated that they did not give any report to paramedics that Resident 1 (R1) had a Dementia diagnosis. An interview with R1 confirmed that R1 does not have dementia. Based on interview, this allegation is UNSUBSTANTIATED. *** Continuation in LIC9099C *** Unsubstantiated #2 Staff did not allow resident to view their records- Based on interviews, 3 out of 3 staff stated that all residents have access to their files and can request them at any time. An Interview with Resident 1 (R1) stated that when they requested access to see “where in the file resident has dementia” staff were unable to provide the information because this information was not documented. When LPAs reviewed R1’s file, the Physician’s Report did not state that R1 has dementia. Based on interview and record review, this allegation is UNSUBSTANTIATED. During the investigation, LPA did not find evidence to corroborate the allegations. Based on the evidence, the allegations mentioned above are UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur. An exit interview was conducted where this report, LIC9099, LIC909C, were discussed and copies provided to Director of Operations and Clinical Services Dorie Loo.the state’s words, verbatim · CDSS document, Sep 8, 2025 · control 56-AS-20250904150342

Allegation investigated: Staff are not properly addressing a rodent infestation in the facility

On 1/02/2025 at 1:50 PM, Licensing Program Analyst (LPA) Eldin Serrano made an unannounced visit to the facility to deliver the findings of the above allegation. LPA Serrano explained the purpose of the visit to a staff. Staff informed the Administrator Lynette Humphrey of the visit. Administrator met with LPA Serrano and LPA explained the purpose of the visit to Administrator Humphrey. The investigation was conducted by LPA Serrano. The investigation consisted of records review and interviews with relevant parties as well as observation. The allegations indicate: Staff are not properly addressing a rodent infestation in the facility– Based on record review and relevant party interviews, 4 out of 4 interviews indicated that there were rodents’ activity in the facility, but it was addressed by the facility management. *** Continuation in LIC9099C *** Unsubstantiated The interview with the administrator Lynette Humphrey stated preventative measures have been taken to address concerns of rodents and provided current records that reflect preventative measures have been put in place to avoid rodents being in the facility. The administrator provided a contract with a pest control management company. They have a monthly service frequency in their pest control agreement. The administrator also provided the November 2024 invoice and the pest management company current invoice for their service of the facility in December 2024. LPA toured the facility and did not observe any signs of rodent’s activity during inspection. During the investigation, LPA did not find evidence to corroborate the allegations. Based on the evidence, the allegations mentioned above are UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means 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 at this time. An exit interview was conducted where this report, LIC9099 was discussed and provided to Administrator Lynette Humphrey.the state’s words, verbatim · CDSS document, Jan 2, 2025 · control 56-AS-20241220091438

Allegation investigated: Facility has rodents.

Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to the facility to initiate and deliver findings for the mentioned allegation. LPA met with Lynette Humphrey-Administrator who was informed of the purpose of the visit and allegation. The investigation consisted of interviews with staff member, residents, records review, and observations. LPA Allen conducted interviews with staff members and residents who have stated rodents have been seen and administration has taken measures to address the concerns. The interview with the administrator Lynette stated preventative measures have been taken to address concerns of rodents and provided current records that reflect preventative measures have been put in place to avoid rodents being in the facility. LPA toured the facilities kitchen area, storage area, bedrooms and bathrooms of residents and LPA didn't see any signs of rodents’ droppings during the inspection. Unsubstantiated Based on the evidence gathered during the investigation, the above allegation is found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted where this report was discussed and provided to Lynette Humphrey- Administrator at the conclusion of the visit.the state’s words, verbatim · CDSS document, Nov 25, 2024 · control 56-AS-20241121092042

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA’s) Bernadette Allen made an unannounced visit to the facility to conduct a required comprehensive annual inspection. LPA met with Lynette Humphrey- Administrator who assisted with the tour of the facility. Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature 75-78 degrees throughout the facility. LPA inspected resident’s bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. The hot water temperature measured between 105- and 120 degrees F. throughout the facility. LPA observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors, fully charged fire extinguisher, and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. LPA observed there was a designated storage space for resident/staff files. Medications are kept locked in the medication room inaccessible to residents in care. Overall, the facility is clean, in good repair, and operating in safe condition. Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department. Record Review: LPA reviewed four (4) resident files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed five (5) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. Medications were audited at random and appeared to be dispensed appropriately by staff members. P&I was randomly checked and appeared to balance with ledger. Based on the observations made during today’s visit, no deficiencies were cited. An exit interview was conducted, and this report was discussed and provided to Lynette Humphrey- Administrator at the conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Nov 13, 2024

Allegation investigated: Licensee does not ensure the facility has running water Licensee does not ensure the facility has working toilets Licensee does not ensure facility is adequately staffed to meet resident's needs. Licensee does not ensure facility is adequately staffed to meet resident's toileting needs. Facility staff do not provide adequate food service to residents.

Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to initiate and deliver findings for the mentioned allegations. LPA met with Kara Richardson Customer Liaison who was informed of the purpose of the visit and allegations. The investigation consisted of interviews with staff, residents, record review, and observations. LPA toured the facility and seven (7) resident’s rooms and observed that all toilets in the rooms were operating/flushing and there was running hot water that measured between 105-110 degrees. LPA also observed the kitchen staff washing dishes with hot water. Residents were interviewed and they stated they receive the help that they need but it comes slow sometime and additional staff would be helpful. The residents stated that the food service is good to them, and they don’t have any complaints. LPA observed residents in the dining area eating a balanced lunch baked chicken, mashed potatoes, green peas, fruit, water, and juice. There was also a menu avaliable for review. Unsubstantiated Staff members were interviewed, and they stated additional staff is needed to meet the needs of the residents in care, but they work with who they have. LPA interviewed the licensee Mr. Braswell who stated he is aware additional staff is needed which is being addressed and interviews were currently being conducted and they have potential staff who have been cleared for employment and training is due to start in a week or two. Based on interviews, observations and evidence gathered during the investigation, the above allegation is found to be Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted and discussed with Kara Richardson Customer Liaison and a copy of the report was provided at the conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Sep 19, 2024 · control 56-AS-20240917092819

Allegation investigated: Resident sustained unexplained burns while in care Resident’s burns have worsened due to staff neglect

Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to initiate and deliver findings for the mentioned allegations. LPA met with Kara Richardson Customer Liaison who was informed of the purpose of the visit and allegations. The investigation consisted of interviews with outside parties, staff, residents, record review, and observations. LPA Allen conducted an interview with Resident 1 (R1) who stated a staff member dropped coffee on their leg and foot while serving them breakfast in bed. R1 stated they could not recall who the staff member was, but there was a witness who could possibly confirm the allegation. LPA attempted to interview Resident 2 (R2) but they could not confirm or deny the allegations. The interviews with staff members have stated they observed unexplained scaring thought to be burns on R1’s body but no longer believe R1 was ever burned, and the scaring has inproved since additional care has been provided. Unsubstantiated LPA observed R1 receiving additional care from an outside party who stated R1 was not being treated for burns and documents reviewed didn’t reveal R1 was burned but was being treated for another health condition. Based on interviews, observations and evidence gathered during the investigation, the above allegation is found to be Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted and discussed with Kara Richardson Customer Liaison and a copy of the report was provided at the conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Sep 19, 2024 · control 56-AS-20240917173429

Allegation investigated: Licensee does not ensure facility has running water. Staff do not assist resident with wound care.

Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to the facility to initiate the complaint investigation and deliver findings. LPA met with administrator Keely Miller who was informed of the visit. The investigation consisted of observations, records review, and interviews with residents and staff members. Allegation 1. The residents and staff members stated alternative measures were taken to ensure staff and residents had access to water while the water was turned off by the water company. LPA observed an overflow of water in the administrator’s office, and running water througout the facility. It was observed that additional water was purchased. Allegation 2. Interviews conducted with facility staff, facility residents, and records reviewed revealed there are no residents that require, or are receiving wound care. Unsubstantiated Based on interviews conducted with facility staff, residents and review of documentation the mentioned allegations are Unsubstantiated. A finding of unsubstantiated means although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted, and this report (LIC9099) was discussed and provided to Administrator Keely Miller along with a copy of the appeal rights.the state’s words, verbatim · CDSS document, Aug 5, 2024 · control 56-AS-20240801095457

Allegation investigated: Staff withheld residents debit card.

Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to investigate and deliver findings for the allegation listed above. LPA stated the purpose of the visit, was granted entry, and met with Administrator Keely Miller. The investigation consisted of resident interviews, staff interviews, and document review. For allegation, Staff withheld residents debit card. It was alleged that the facility had Resident R1’s debit card in their possession. Interviews with the staff revealed that Resident R1 is self-responsible and does not have a conservator or power of attorney. It was revealed that R1 requested the facility to secure R1’s debit card in a lock box in the front office. R1 signed a document on upon admission on 2/22/2024 allowing the facility to safeguard R1’s debit card. The facility provided R1 full access to obtain the debit card when requested. The staff denied withholding the debit card from R1. Unsubstantiated The staff denied knowing the PIN number to the debit card. The staff denied that purchases were made by the staff using the debit card. On 3/4/2024, the staff asked R1 if they wanted to open a trust account to safeguard funds but R1 denied and continued to return the debit card to the front office. During today’s visit, the Administrator informed LPA that they would contact R1’s family to inquire about conservatorship over finances. If the family does not want to be involved with R1’s finances, the Administrator will contact the County of San Bernardino to inquire if a county conservatorship over finances would fit R1’s financial needs. Interview with R1 revealed that upon admission to the facility R1 asked the facility to safeguard their debit card. R1 willingly signed a document allowing the facility to secure R1’s debit card in the front office. R1 did not have concerns about purchases made with their debit card. R1 denied that their debit card was withheld from R1. R1 informed LPA that they changed their mind, would like the debit card returned, and wants to discontinue the facility from securing the debit card. Interviews with additional residents at the facility did not reveal information that other residents had issues with the facility safeguarding or handling their finances. A document review of R1’s record revealed that R1 is self-responsible, does not have a conservator, and does not have a power of attorney. R1’s admission agreement was signed and dated on 2/22/2024. On 2/22/2024, R1 signed a document allowing the facility to safeguard their debit card. A document review of R1’s record revealed notes for outings on 2/22/2024, 3/4/2024, and 3/11/2024 where R1 used their debit card to make purchases. During today’s visit, R1’s debit card was returned to R1 and is no longer in possession of the facility. Overall, there was not enough evidence to collaborate the allegation listed above. Based on evidence obtained during the investigation, the allegation listed above is deemed UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means 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. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) was discussed and provided Administrator Keely Smith, along with a copy of the appeal rights.the state’s words, verbatim · CDSS document, Mar 15, 2024 · control 56-AS-20240311093246

Allegation investigated: Licensee does not ensure facility has running hot water within required temperatures Licensee does not ensure tap water is safe for consumption Staff does not ensure facility is kept in clean sanitary conditions at all times Staff does not ensure facility is kept free of insects Staff does not ensure waste is properly disposed of for residents in care Staff does not ensure fresh clean linens are provided for residents in care

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding the above allegations. LPA Prieto met with Administrator Miller and explained the elements of the complaint. Regarding the allegation that Licensee does not ensure facility has running hot water within required temperatures; LPA Prieto tour facility rooms (#33, 40, 36, 22, 23, 24, 39, 42, 1 and 6) and with the aid of staff #1 (S1) and S2, water temperatures were tested and found to be within allowable temperatures per Regulation and averaging 113 degrees Fahrenheit. ***continued on LIC 9099C*** Unsubstantiated Regarding the allegation that Licensee does not ensure tap water is safe for consumption; report from the Yucaipa Valley Water District states it met all drinking water quality standards based on over 1, 500 water samples collected throughout the calendar year and reported by independent laboratories to the Division of Drinking and USEPA. Regarding the allegation that Staff does not ensure facility is kept in clean sanitary conditions at all times; LPA Prieto toured the facility, with the assistance of S1 and S2 and found that the common areas, hallways and dining areas are clean and free of obstruction. LPA inspected ten (10) resident rooms and found them to be clean and sanitary. Regarding the allegation that Staff does not ensure facility is kept free of insects; LPA Prieto toured the facility, with the assistance of S1 and S2 and found that the common areas, hallways and dining areas are clean and free of insects. LPA inspected ten (10) resident rooms and found them to be free of insects. Records obtained by LPA shows the facility has service from an Exterminator company to spray the facility on a monthly basis. Regarding the allegation that Staff does not ensure waste is properly disposed of for residents in care; LPA inspected ten (10) resident rooms and found that the waste was properly being disposed of. Resident #1 (R1, R2, R3, R4, R5, & R6) were interviewed in their rooms and state that there waste is being disposed of by staff during regular cleaning hours. Regarding the allegation that Staff does not ensure fresh clean linens are provided for residents in care; LPA inspected ten (10) resident rooms and found that fresh linen was being provided during regular clean hours. Resident #1 (R1, R2, R3, R4, R5, & R6) were interviewed in their rooms and state that their linens were being supplied by staff during regular cleaning hours. Records retrieved by LPA showing linens are sent out to a cleaning company and returned to then facility on a regular basis. ***continued on LIC 9099C*** Based on the information obtained there is not enough evidence that Licensee does not ensure facility has running hot water within required temperatures, Licensee does not ensure tap water is safe for consumption, Staff does not ensure facility is kept in clean sanitary conditions at all times, Staff does not ensure facility is kept free of insects ,Staff does not ensure waste is properly disposed of for residents in care and Staff does not ensure fresh clean linens are provided for residents in care. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Administrator Miller and a copy of the report was left with the facility.the state’s words, verbatim · CDSS document, Feb 12, 2024 · control 56-AS-20240206134320

Allegation investigated: Staff put poison in residents food Staff put animal feces in residents food Due to lack of supervision, resident was hit by another resident

**This is an Admended report**** Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced complaint visit to the facility. LPA met with Keely Miller, Administrator and discussed the purpose of the visit. Regarding the allegations, staff put poison in residents’ food and staff put animal feces in residents’ food. LPA toured the kitchen and did not observe toxins stored in food areas. Staff interviewed deny putting poison and animal feces in residents' food. Six (6) residents interviewed stated they have not had food poisoning and have not witnessed staff put feces in residents’ food. Regarding the allegation, Lack of supervision resulted in resident being hit by another resident. It is alleged that a resident was hit by another resident and staff did not intervene. Staff interviews reveal, staff do intervene when they witness any altercations between residents. Five (5) out of (6) residents interviewed deny witnessing a resident being hit and staff not intervening. Based on interviews and pertinent record review, there is not a preponderance of evidence to prove the alleged violations did or did not occur; therefore the above allegations are Unsubstantiated; An exit interview was conducted where this report was discussed, and a copy was provided to Administrator Miller at the conclusion of the visit. Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 9, 2024 · control 56-AS-20240202150207

Type of visit: Required - 1 Year

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.the state’s words, verbatim · CDSS document, Nov 29, 2023

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.