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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565802467
Report Date: 05/22/2023
Date Signed: 05/22/2023 09:49:27 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/01/2022 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20220201121402
FACILITY NAME:PALMS AT BONAVENTURE ASSISTED LIVING, THEFACILITY NUMBER:
565802467
ADMINISTRATOR:MCCAULEY, BRANDYFACILITY TYPE:
740
ADDRESS:111 N WELLS ROADTELEPHONE:
(805) 647-0616
CITY:VENTURASTATE: CAZIP CODE:
93004
CAPACITY:121CENSUS: 92DATE:
05/22/2023
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Brandy McCauleyTIME COMPLETED:
09:55 AM
ALLEGATION(S):
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Insufficient staffing
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to deliver the findings for the above allegations. The LPA met with Executive Director Brandy McCauley and explained the reason for the visit.

On 2/08/2022, LPA Joann Rosales conducted a visit from 11:00 a.m. – 4:30 p.m., in which LPA Rosales toured the facility, interviewed staff and residents, and obtained documents. On 02/28/2022, LPA Rosales conducted a subsequent visit from 10:55 a.m. – 4:10 p.m., in which LPA Rosales interviewed random residents and staff, and obtained additional documents.

The allegation of ‘insufficient staffing’ alleges that the facility was understaffed in January and February of 2022, which resulted in staff being required to work with residents although staff were positive with COVID-19. Per interviews conducted by LPA Rosales on 2/8/2022 and 2/28/2022, staff revealed that a number of staff were requested to work, despite being symptomatic and COVID-19 positive.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2023
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 5
Control Number 29-AS-20220201121402
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: PALMS AT BONAVENTURE ASSISTED LIVING, THE
FACILITY NUMBER: 565802467
VISIT DATE: 05/22/2023
NARRATIVE
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Per PIN 21-23, which discussed quarantine and isolation guidelines for asymptomatic and symptomatic staff, staff that are COVID-19 positive should isolate until at least 10 days have passed since symptoms first appeared. Per staff interviews of staff who were COVID-19 positive, approximately 3-5 days would pass since the onset of symptoms, and they were required to work. Despite this, staff indicated that they were still understaffed and at times, would only have one medication technician or 1-2 caregivers per shift. Staff interviews revealed that because of insufficient staffing, there were at times not enough staff to meet all caregiving needs. As a result, staff admitted that residents would not receive showers, staff were unable to fulfill laundering duties, and residents were not being checked. Interviews conducted with a private caregiver further revealed that staff were unable to respond to pendant lights timely, rooms were not cleaned regularly, and showers were not given twice a week. A review of the Daily Assignments list from February 2022 revealed that care staff were assigned approximately fifteen rooms per shift. With experienced call-offs and/or people not cleared to work, this number would increase.

Whereas it was alleged that resident #1 (R1) had fallen and was on the floor for an extended period of time, there was insufficient evidence to support this claim, as staff alleged that they regularly checked residents, and staff responded to R1 when they pressed the pendant for assistance for this specific fall. If staff check on residents every 2 hours, it is unknown as to when staff checked on R1 before R1 was found on the floor. Although it was alleged that R1 claimed to have been on the floor for an hour, R1 denied this claim during an interview. Based on the information obtained, there is sufficient evidence to support the allegation occurred. Therefore, the allegation of ‘insufficient staffing’ is deemed substantiated at this time.

Pursuant to Title 22 Regulations, deficiencies were cited (refer to LIC 9099-D). Exit interview conducted, today's report and appeal rights were issued.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 29-AS-20220201121402
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PALMS AT BONAVENTURE ASSISTED LIVING, THE
FACILITY NUMBER: 565802467
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/24/2023
Section Cited
CCR
87411(a)
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87411(a) Personnel Requirements. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by:
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The Administrator agreed to the following:
1. Submit a Staffing Plan by 5/24/2023. Staffing Plan shall detail the efforts the licensee has employed to ensure adequate staffing in all departments in the event of a critical staff shortage.
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Based on interviews and record review, the licensee did not comply with the section cited above as the facility had an inadequate number of staff to meet the residents care needs, which poses an immediate health and safety risk to residents in care.
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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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/01/2022 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20220201121402

FACILITY NAME:PALMS AT BONAVENTURE ASSISTED LIVING, THEFACILITY NUMBER:
565802467
ADMINISTRATOR:MCCAULEY, BRANDYFACILITY TYPE:
740
ADDRESS:111 N WELLS ROADTELEPHONE:
(805) 647-0616
CITY:VENTURASTATE: CAZIP CODE:
93004
CAPACITY:121CENSUS: 92DATE:
05/22/2023
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Brandy McCauleyTIME COMPLETED:
09:55 AM
ALLEGATION(S):
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Facility did not safeguard resident personal property
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to deliver the findings for the above allegations. The LPA met with Executive Director Brandy McCauley and explained the reason for the visit.

On 2/08/2022, LPA Joann Rosales conducted a visit from 11:00 a.m. – 4:30 p.m., in which LPA Rosales toured the facility, interviewed staff and residents, and obtained documents. On 02/28/2022, LPA Rosales conducted a subsequent visit from 10:55 a.m. – 4:10 p.m., in which LPA Rosales interviewed random residents and staff, and obtained additional documents.

The allegation of ‘Facility did not safeguard resident personal property’ alleges that resident #1 (R1) had a ring stolen from them, and resident #2 (R2) had money stolen from their wallet. A review of R1’s personal property inventory list indicated that R1 indeed had two rings. Staff interviews revealed that in general, staff were unaware of R1’s missing ring.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20220201121402
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: PALMS AT BONAVENTURE ASSISTED LIVING, THE
FACILITY NUMBER: 565802467
VISIT DATE: 05/22/2023
NARRATIVE
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An interview with the Administrator indicated that they were notified of R1 missing a ring on 1/29/2022. After searching for the ring, the staff were unable to locate R1’s property. Administrator had talked to R1’s responsible party, who indicated the possibility that R1 had misplaced one or more of the rings when R1 was hospitalized on 1/22/22.

Regarding R2, R2 claimed that they had money taken from their purse in the amount of $45. R2 also stated that they did not lock their door, as staff had a key to their room. The staff who had been alleged to have taken R2’s money was interviewed, yet staff denied all allegations. Insufficient evidence was obtained from staff interviews, as staff either denied knowledge of this incident, or the staff who was accused of this incident was interviewed yet further information was not obtained. The Administrator indicated that they were ‘unsure’ of the amount of money that R2 claimed was missing. At this time, it does not appear that the facility staff failed to safeguard resident personal property. Based on the information gathered the allegation is unsubstantiated, at this time.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5