565802467-6-15-2023-29-AS-ECOZ-CSTMG6-20230615093525

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565802467
Report Date: 06/15/2023
Date Signed: 06/15/2023 09:35:38 AM

Document Has Been Signed on 06/15/2023 09:35 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	PALMS AT BONAVENTURE ASSISTED LIVING, THE		FACILITY NUMBER:	565802467
ADMINISTRATOR:	MCCAULEY, BRANDY		FACILITY TYPE:	740
ADDRESS:	111 N WELLS ROAD		TELEPHONE:	(805) 647-0616
CITY:	VENTURA	STATE: CA	ZIP CODE:	93004
CAPACITY:	121	CENSUS: 96	DATE:	06/15/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Brandy McCauley		TIME COMPLETED:	09:35 AM

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) Esther Cortez conducted a subsequent Case Management - Incident visit. The purpose of the visit is to conclude an investigation initiated by LPA Martha Arroyo and Esther Cortez on 03/14/2023. LPA met with administrator Brandy McCauley and explained the reason for the visit. On 03/09/2023, the Department received a Special Incident Report (SIR) regarding Resident #1 (R1). The report stated that on 03/07/2023, R1’s roommate alerted staff that R1 was on their bed bleeding from a fall. Staff observed R1 on top of their bed bleeding from the right temple area on their face. R1 was unable to recall how the incident occurred. R1’s roommate stated they were standing at the end of the bed talking when R1 turned to walk away, R1’s feet got tangled causing R1 to fall. R1 was admitted to Community Memorial Hospital for evaluation and treatment and subsequently died on 03/09/2023 of a subdural hematoma. During the initial visit on 03/14/2023, the LPA’s interviewed the Executive Director at 4:00pm and requested documents pertinent to the investigation. The incident was referred to Community Care Licensing Investigations Branch (IB) and assigned to IB Investigator Christine Ferris. Investigator Ferris conducted interviews on 03/28/2023 with residents, staff, and Memory Care Coordinator. In addition, the investigator reviewed Community Memorial Hospital medical records, facility file documents related to R1, and County of Ventura Certificate of Death. Report will continue on LIC809-C

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023

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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PALMS AT BONAVENTURE ASSISTED LIVING, THE	FACILITY NUMBER: 565802467
	VISIT DATE: 06/15/2023

NARRATIVE

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The medical records reviewed revealed that on 03/07/2023, R1 arrived at Community Memorial Hospital for an evaluation of a head injury due to a ground-level mechanical fall that occurred at 1:00 p.m. on 03/07/2023. The report states R1 experienced the fall in their bedroom at the facility. At presentation, R1 only reported severe headache. R1 also had a hematoma to the right eye, laceration above the right eye, and skin tears to the right arm, wrist, and hand. Per the Emergency Department (ED) staff, R1 was initially conversant, but became unresponsive after the computerized tomography (CT) exam. Neurosurgery was consulted and recommended to repeat imaging to evaluate for possible surgical intervention. The CT scan performed at 2:00 p.m., demonstrated a large right cerebral acute subdural hematoma measuring 2cm in thickness with right to left midline shift of 8mm. The CT scan performed at 4:00 p.m., demonstrated interval increase in size of hematoma measuring up to approximately 3.1cm in thickness and there is a right to left shift of 23mm. There was poor prognosis and no plans for surgical intervention. Per the attending physicians’ recommendations, R1 was placed on comfort measures due to R1’s advanced age, dementia, poor neurological condition, and rapidly expansive acute subdural hematoma with midline shift. On 03/09/2023 at 12:59 a.m., R1 was pronounced dead and R1’s resident representative notified. The County of Ventura Certificate of Death listed the immediate cause of death as blunt force head injury with subdural hematoma. The injury occurred due to ground level fall and was listed as an accident.

Per the review of R1’s needs and services plan, R1 did not require 1 to 1 care and was able and allowed to ambulate while in their room without assistance. The fall occurred while R1 was ambulating in their own room and the witness, R1’s roommate, described the incident as accidental. Per the interviews with the staff, all were consistent saying R1 was ambulatory, independent, and used a walker on and off. When staff would bring the walker to R1 or remind R1 to use the walker, R1 would refuse to use it.

Report will continue on LIC809-C

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023

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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PALMS AT BONAVENTURE ASSISTED LIVING, THE	FACILITY NUMBER: 565802467
	VISIT DATE: 06/15/2023

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 26 27 28 29 30 31 32	Based on the information and documentation obtained and reviewed, the Department does not have sufficient evidence to determine that staff failed to provide adequate supervision to R1 resulting in R1 falling in room, sustaining a subdural hematoma, and subsequently passing away at the hospital. Exit interview, copy of report given.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023

LIC809 (FAS) - (06/04)

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